RN Navigator: High-Risk Surgical Care & Care Coordination

massgeneralbrigham; Somerville (MA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Mass General Brigham seeks a Registered Nurse Navigator (RNN) to join the Population Health Services Organization in a hybrid role, with three days on-site per week at Newton Wellesley Hospital. The RNN focuses on high-risk and medically complex surgical patients within the CMS Transforming Episode Accountability Model (TEAM).

The RNN will coordinate care across pre-operative and post-discharge phases, supporting APPs, PTNs, and involved physicians to ensure a smooth episode of care and reduce

Responsibilities

• Management of high-risk and medically complex patients across pre-operative and post-discharge phases
• Pre-operative clinical assessments, functional and social evaluation of patients
• Perform medication reconciliation as part of pre-operative optimization
• Risk identification requiring escalation or intervention
• Collaboration with Coordinators, PTNs, APPs, physician offices, inpatient care teams to ensure coordinated episode management
• Support post-discharge follow-up, anticipatory guidance, patient education, and clinical triage for complex cases
• Projection of expected hospital course for identified surgical patients, including barriers to timely discharge

Job description

Mass General Brigham seeks a Registered Nurse Navigator (RNN) to join the Population Health Services Organization in a hybrid role, with three days on-site per week at Newton Wellesley Hospital. The RNN focuses on high-risk and medically complex surgical patients within the CMS Transforming Episode Accountability Model (TEAM).

The RNN will coordinate care across pre-operative and post-discharge phases, supporting APPs, PTNs, and involved physicians to ensure a smooth episode of care and reduce