Post Acute Care RN Navigator - ACO

Trinity Health; Waterbury (CT); On-site; USD 85,000 - 110,000; Full time

Job summary

Trinity Health Of New England is seeking a Registered Nurse to support the Clinically Integrated Network post-acute strategy, overseeing MSSP Three Day Rule Waiver and coordinating patient transitions from hospital to SNF and home.

You will work with case management, discharge planning, utilization management and care teams to reduce readmissions, with full-time day shifts across CT/MA networks.

Qualifications

• Current RN license in CT and MA in good standing.
• Bachelor’s degree in nursing is required.
• Minimum two years in an ACO or value-based care setting.
• Minimum two years in case management or discharge planning preferred.

Responsibilities

• Interface with hospitals’ Case Management to coordinate discharge planning.
• Collaborate with network SNFs to transition patients from hospital to SNF.
• Ensure smooth transitions of care and handoffs to care management.
• Work with acute care, skilled nursing, and home health teams on transitions.
• Use payor and internal data to identify high‑risk patients and prevent readmissions.

Skills

Care coordination

Discharge planning

Utilization management

Interdisciplinary collaboration

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!

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.