Care Continuum Nurse Navigator

Penn Medicine, University of Pennsylvania Health System; Philadelphia (Philadelphia County); Hybrid; USD 90,000 - 115,000; Full time

Job summary

Clinical Care Associates (CCA) – Penn Primary Care (PPC) and Penn Specialty Practices (PSP) of Penn Medicine Medical Group (PMMG) seeks a Care Continuum Nurse Navigator. This RN serves as the primary clinical liaison across acute and post-acute settings, coordinating care transitions within MSSP frameworks to ensure safe, cost-effective discharge planning and placement.

The role drives LOS optimization, reduces readmissions, and collaborates with physicians, social workers, and post-acute

Qualifications

• Bachelor’s degree in Nursing or related field required.
• Minimum 5+ years of experience in an acute care setting.
• PA RN License required.

Responsibilities

• Coordinate timely transitions to post-acute settings (SNF, LTAC, IRF, HHA, hospice) within Penn Medicine’s network.
• Perform concurrent clinical review of referrals to ensure appropriate level of care and medical necessity.
• Maintain knowledge of network capabilities, bed availability, and payer requirements.
• Partner with care teams to identify discharge barriers and support timely progression.
• Conduct daily discharge readiness assessments and participate in multidisciplinary rounds.
• Track LOS data and identify patterns for system-wide improvement.
• Ensure MSSP ACO standards and quality measure capture are met.
• Educate patients and families on post-acute options and care transitions.
• Monitor LOS, readmissions, and post-acute data to identify trends and improvement opportunities.
• Occasionally travel to post-acute facilities for site visits and audits.

Skills

Care coordination

Nursing

Patient education

Interdisciplinary collaboration

Education

Bachelor's Degree in Nursing

Healthcare management or related field

Master's Degree in Nursing or Healthcare Management

PA RN License

Tools

Arcadia

Repisodic

Point-Click-Care

SlicerDicer

Power BI

Job description

Entity: Clinical Care Associates (CCA) - Penn Primary Care (PPC) and Penn Specialty Practices (PSP) of Penn Medicine Medical Group (PMMG)

Location: 150 Monument Road

Hours: Per Departmental Needs (Remote)

Summary:

The Care Continuum Nurse Navigator is a registered nurse who serves as the primary clinical liaison between the acute care setting, post-acute care providers, patients, and families during care transitions. Functioning within Penn Medicine's accountable care and value-based care frameworks, including the Medicare Shared Savings Program (MSSP), this role demonstrates advanced care coordination and transition management expertise to ensure safe, appropriate, and cost-effective discharge planning and post-acute placement. Leveraging Penn Medicine's preferred post-acute care network, the role applies clinical judgment and evidence-based practice to align patient needs, payer requirements, and organizational priorities.

The Care Continuum Navigator drives optimal post-acute length-of-stay (LOS) management, reduces avoidable readmissions, and coordinates complex care transitions with a focus on quality outcomes, regulatory compliance, and patient-centered care. In collaboration with physicians, social workers, utilization management nurses, case managers, and post-acute providers, this role addresses barriers to discharge, aligns care plans with clinical criteria and patient goals, and supports successful outcomes across the continuum of care.

Accountabilities:

Post-Acute Care Coordination & Preferred Network Optimization

• Coordinate timely, clinically appropriate transitions to post-acute settings (SNF, LTAC, IRF, HHA, hospice), prioritizing Penn Medicine’s preferred, high-performing network.
• Perform concurrent clinical review of referrals to ensure appropriate level of care and medical necessity.
• Maintain knowledge of network capabilities, bed availability, and specialty services; align placements with payer requirements and MSSP attribution.

Length-of-Stay (LOS) Management

• Partner with care teams in both the hospital and post-acute settings to identify and resolve discharge barriers supporting timely patient progression.
• Conduct daily discharge readiness assessments and participate in multidisciplinary rounds to align care plans with target discharge dates.
• Track and trend LOS data at the unit and patient level, identifying patterns and contributing to system-wide performance improvement initiatives.
• Escalate LOS concerns and analyze LOS trends to support performance improvement.

MSSP & Value-Based Care Alignment

• Ensure compliance with MSSP ACO standards, including attribution tracking, care coordination, and quality measure capture.
• Collaborate with the Population Health and ACO teams to ensure post-acute placements support MSSP shared savings goals and quality benchmarks including readmission rates, patient experience, and total cost of care.
• Support documentation and initiatives that close care gaps and improve MSSP performance outcomes.

Patient & Family Engagement

• Educate patients and families on post-acute options and care transitions to support informed decision-making.
• Use motivational interviewing and teach-back to promote engagement and self-management.
• Advocate for patient preferences and facilitate advance care planning discussions and education.
• Coordinate with community health workers, social workers, and primary care providers to address Social Drivers of Health (SDOH) that may affect care transition success.

Data, Documentation & Quality Improvement

• Monitor and interpret LOS, readmissions, and post-acute data to identify trends and improvement opportunities.
• Utilize various data tools to capture patient data including: Aracadia, Repisodic, Point-Click-Care, SlicerDicer, Quality Analytics Application PowerBI, and payer provider performance reports.[MA2.1]
• Contribute to quality initiatives, reporting outcomes and supporting system-wide performance improvement.
• Occasionally travel to post-acute care facilities within the Penn Medicine preferred network for site visits, partner meetings, or quality audits.
• Ability to work in a hybrid capacity (on-site and remote).

Education/Experience:

Required: Bachelor's Degree Nursing, Healthcare management or related field And 5+ years Experience in an acute care setting.

PA RN License

Preferred: Master's Degree Nursing, Healthcare Management, or related field 1+ years Leadership experience