RN Navigator: Post-Acute Care & Transitions

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

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.