Post Acute Care RN Navigator - ACO

Trinity Health Of New England; Waterbury (CT); Hybrid; USD 75,000 - 115,000; Full time

Job summary

Trinity Health Of New England’s Saint Francis Hospital in Waterbury seeks an experienced RN to support the Clinically Integrated Network post-acute strategy, focusing on discharge planning, transitions of care, and collaboration with hospitals, SNFs, and home health teams.

This on-site role requires CT/MA RN license, a nursing degree, and at least two years in an Accountable Care Organization or value-based setting; residency is required due to on-site work. Full-time, day shift.

Qualifications

• Current RN License in CT and MA required (assistance provided to obtain secondary State license if needed).
• Bachelor’s degree in nursing required.
• Minimum of two (2) years working within an Accountable Care Organization (ACO) or medical group participating in value-based contracts.
• Minimum two (2) years experience in case management, discharge planning, utilization management, or post-acute care settings preferred.

Responsibilities

• Interface with hospitals’ Case Management team to help coordinate the discharge planning of patients
• Collaborate with network SNFs to transition patients from hospital to SNF including planning safe discharge home
• Collaborate with all care team members involved in patients’ hospitalization and SNF admission and ensuring smooth transitions of care and handoffs to care management
• Collaborate with care teams such as acute care, skilled nursing, and home health agencies to effectively manage and transition patients
• Utilize payor and internal reporting sources to identify high-risk patients who may need additional support and/or follow up when discharging home to reduce risk of readmission

Skills

RN license CT/MA

Nursing degree

ACO experience

Discharge planning

Education

Bachelor's degree in nursing

Job description

Employment Type: Full time Shift: Day Shift Description: Be part of the team in our Clinically Integrated Network program based out of Saint Francis Hospital, part of Trinity Health Of New England!

Local residency required due to on site work 50% of the time

Position Purpose

Responsible for supporting the implementation of the THOfNE CIN post-acute strategy, including primary oversight of the Medicare Shared Savings Program (MSSP) Three Day Rule Waiver program.

What you will do

• Interface with hospitals’ Case Management team to help coordinate the discharge planning of patients
• Collaborate with network SNFs to transition patients from hospital to SNF including planning safe discharge home
• Collaborate with all care team members involved in patients’ hospitalization and SNF admission and ensuring smooth transitions of care and handoffs to care management
• Collaborate with care teams such as acute care, skilled nursing, and home health agencies to effectively manage and transition patients
• Utilize payor and internal reporting sources to identify high-risk patients who may need additional support and/or follow up when discharging home to reduce risk of readmission

Minimum Qualifications

• Current RN License in good standing in CT and MA required (assistance provided to obtain secondary State license if needed)
• Bachelor’s degree in nursing required
• Minimum of two (2) years working within an Accountable Care Organization (ACO) or medical group participating in value-based contracts
• Minimum two (2) years experience in case management, discharge planning, utilization management, or post-acute care settings preferred

Position Highlights and Benefits

Full time 40hr salaried M-F days

Ministry/Facility Information

Trinity Health Of New England is an integrated health care delivery system comprised of world-class providers and facilities dedicated to the full spectrum of preventive, acute, and post-acute care, all delivered with the triple aimof better health, better care, and lower costs for our patient populations

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.