RN Navigator - Pre​/Post Surgical Optimization

Job Summary

This is a hybrid position that requires three days per week on-site at Newton Wellesley Hospital. The role is a Registered Nurse Navigator (RNN) focused on high-risk and medically complex surgical patients within the CMS Transforming Episode Accountability Model (TEAM). The RNN will coordinate care for Medicare patients undergoing one of five specified surgical procedures, managing care from surgery through the first 30 days post‑discharge to improve patient experience and reduce readmissions.

The PHSO is developing standard, patient-centered episodic operational pathways to support care delivery and outcomes. Program goals include mitigating risk, patient optimization, reduced length of stay, continuity of care, and positive long‑term health outcomes.

• Management of high-risk and medically complex patients across pre-operative and post-discharge phases
• Pre-operative clinical assessments, functional and social evaluation of patients
• Perform medication reconciliation as part of pre-operative optimization
• Risk identification requiring escalation or intervention
• Pre-operative clinical, functional, and social assessment using RAPT and FRAIL assessments
• Collaboration with Coordinators, PTNs, APPs, physician offices, inpatient care teams to ensure coordinated episode management
• Support post-discharge follow-up, anticipatory guidance, patient education, and clinical triage for complex cases
• Project expected hospital course and identify barriers to timely discharge or discharge destination
• Communicate across internal and external providers, inpatient teams, and post‑acute services
• Participate in quality/process improvement and program development initiatives
• Liaise with physician offices, inpatient healthcare teams, and external agencies
• Communicate test results, coordinate necessary testing, and track completion of pending optimization items
• Maintain all certifications and licensures required to fulfill duties

• Facilitate communication between CMS TEAM program staff and other health care team members
• Participate in the assessment, development, implementation, and evaluation of quality improvement programs, standards of practice, and policies and procedures
• Perform other administrative duties as required by program development and leadership direction

• BSN required
• 5+ years of experience in an acute care setting, provider practice, community-based role, or discharge/transitional planning
• Registered Nurse (RN) licensure in Massachusetts (licensure in adjacent states may be requested)
• Strong clinical assessment and care coordination skills required
• BLS required (or secured within first 3 months of employment)
• Experience with geriatric patient population preferred
• Epic experience preferred
• Experience in perioperative care, ambulatory care management, or complex patient navigation preferred

• Full-time, Monday through Friday, standard business hours
• Hybrid: 3 days per week at Newton Wellesley Hospital and 2 days/month on-site at Assembly Row in Somerville, MA
• Remote work requires a stable, secure, compliant quiet working station

$58,656.00 – $ per year

399 Revolution Drive, Somerville, MA

6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

Applicants who require accommodation in the job application process may contact Human Resources at .