RN Post-Acute Care Navigator: Discharge & Transitions

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

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.