Care Continuum Nurse Navigator (Remote)

Penn Medicine, University of Pennsylvania Health System; Bala Cynwyd (PA); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Penn Medicine is seeking a Care Continuum Nurse Navigator who serves as the primary clinical liaison across acute and post-acute care, patients, and families during transitions. The role emphasizes care coordination within MSSP and value-based frameworks to ensure safe, cost-effective discharge planning.

Collaborate with physicians, social workers, utilization management nurses, and post-acute providers to address barriers to discharge and optimize patient outcomes across the continuum.

Qualifications

• Bachelor's degree in Nursing or related field and PA RN license.
• 5+ years experience in an acute care setting.
• Master's degree preferred; 1+ year leadership experience.

Responsibilities

• Coordinate timely post-acute transitions to Penn Medicine’s network.
• Perform concurrent clinical review of referrals for medical necessity.
• Track LOS data and support performance improvement initiatives.
• Collaborate with physicians, social workers, and post-acute providers to align care plans.

Skills

Care coordination

Discharge planning

Patient education

Quality improvement

Education

Bachelor's degree in Nursing

Healthcare management

PA RN License

Master's degree (preferred)

Tools

Aracadia

Repisodic

Point-Click-Care

SlicerDicer

Power BI

Job description

Penn Medicine is seeking a Care Continuum Nurse Navigator who serves as the primary clinical liaison across acute and post-acute care, patients, and families during transitions. The role emphasizes care coordination within MSSP and value-based frameworks to ensure safe, cost-effective discharge planning.

Collaborate with physicians, social workers, utilization management nurses, and post-acute providers to address barriers to discharge and optimize patient outcomes across the continuum.