Remote Nurse Navigator - Care Transitions & Post-Acute

Penn Medicine; Bala Cynwyd (PA); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Penn Medicine is seeking a Care Continuum Nurse Navigator to serve as the clinical liaison across acute and post-acute care, patients, and families. You will apply advanced care coordination within MSSP and value-based frameworks to ensure safe discharge planning and appropriate post-acute placement.

With a registered nurse background and 5+ years in acute care, you will collaborate with physicians, social workers, and post-acute providers, support LOS optimization, and engage patients in care

Qualifications

• Bachelor's degree in Nursing or related field.
• PA RN license.
• At least 5 years in an acute care setting.
• Strong care coordination and discharge planning skills.
• Hybrid on-site/remote work capability.

Responsibilities

• Coordinate post-acute transitions to SNF, LTAC, IRF, HHA or hospice within the Penn Medicine network.
• Perform concurrent clinical review of referrals to ensure appropriate level of care.
• Monitor LOS, readmissions, and data trends to drive improvements.
• Ensure MSSP/ACO standards and quality measure capture.
• Educate patients and families on post-acute options and care transitions.
• Occasionally travel to post-acute facilities for visits and audits.

Skills

Care coordination

Discharge planning

Interdisciplinary collaboration

Clinical documentation

Education

Bachelor's degree in Nursing

Bachelor's degree in Healthcare Management

Master's degree in Nursing or Healthcare Management

Tools

Aracadia

Repisodic

Point-Click-Care

SlicerDicer

PowerBI

Job description

Penn Medicine is seeking a Care Continuum Nurse Navigator to serve as the clinical liaison across acute and post-acute care, patients, and families. You will apply advanced care coordination within MSSP and value-based frameworks to ensure safe discharge planning and appropriate post-acute placement.

With a registered nurse background and 5+ years in acute care, you will collaborate with physicians, social workers, and post-acute providers, support LOS optimization, and engage patients in care