Care Continuum Nurse Navigator

Penn Medicine PA 19004, US

Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Entity: Clinical Care Associates (CCA) - Penn Primary Care (PPC) and Penn Specialty Practices (PSP) of Penn Medicine Medical Group (PMMG)

Department: Regional Physician Admin

Location: 150 Monument Road

Hours: Per Departmental Needs (Remote)

Summary:

The Care Continuum Nurse Navigator is a registered nurse who serves as the primary clinical liaison between the acute care setting, post-acute care providers, patients, and families during care transitions. Functioning within Penn Medicine's accountable care and value-based care frameworks, including the Medicare Shared Savings Program (MSSP), this role demonstrates advanced care coordination and transition management expertise to ensure safe, appropriate, and cost-effective discharge planning and post-acute placement. Leveraging Penn Medicine's preferred post-acute care network, the role applies clinical judgment and evidence-based practice to align patient needs, payer requirements, and organizational priorities.

The Care Continuum Navigator drives optimal post-acute length-of-stay (LOS) management, reduces avoidable readmissions, and coordinates complex care transitions with a focus on quality outcomes, regulatory compliance, and patient-centered care. In collaboration with physicians, social workers, utilization management nurses, case managers, and post-acute providers, this role addresses barriers to discharge, aligns care plans with clinical criteria and patient goals, and supports successful outcomes across the continuum of care.

Accountabilities:

Post-Acute Care Coordination & Preferred Network Optimization

· Coordinate timely, clinically appropriate transitions to post-acute settings (SNF, LTAC, IRF, HHA, hospice), prioritizing Penn Medicine’s preferred, high-performing network.

· Perform concurrent clinical review of referrals to ensure appropriate level of care and medical necessity.

· Maintain knowledge of network capabilities, bed availability, and specialty services; align placements with payer requirements and MSSP attribution.

Length-of-Stay (LOS) Management

· Partner with care teams in both the hospital and post-acute settings to identify and resolve discharge barriers supporting timely patient progression.

· Conduct daily discharge readiness assessments and participate in multidisciplinary rounds to align care plans with target discharge dates.

· Track and trend LOS data at the unit and patient level, identifying patterns and contributing to system-wide performance improvement initiatives.

· Escalate LOS concerns and analyze LOS trends to support performance improvement.

MSSP & Value-Based Care Alignment

· Ensure compliance with MSSP ACO standards, including attribution tracking, care coordination, and quality measure capture.

· Collaborate with the Population Health and ACO teams to ensure post-acute placements support MSSP shared savings goals and quality benchmarks including readmission rates, patient experience, and total cost of care.

· Support documentation and initiatives that close care gaps and improve MSSP performance outcomes.

Patient & Family Engagement

· Educate patients and families on post-acute options and care transitions to support informed decision-making.

· Use motivational interviewing and teach-back to promote engagement and self-management.

· Advocate for patient preferences and facilitate advance care planning discussions and education.

· Coordinate with community health workers, social workers, and primary care providers to address Social Drivers of Health (SDOH) that may affect care transition success.

Data, Documentation & Quality Improvement

· Monitor and interpret LOS, readmissions, and post-acute data to identify trends and improvement opportunities.

· Utilize various data tools to capture patient data including: Aracadia, Repisodic, Point-Click-Care, SlicerDicer, Quality Analytics Application PowerBI, and payer provider performance reports.[MA2.1]

· Contribute to quality initiatives, reporting outcomes and supporting system-wide performance improvement.

• Occasionally travel to post-acute care facilities within the Penn Medicine preferred network for site visits, partner meetings, or quality audits.

• Ability to work in a hybrid capacity (on-site and remote).

Education/Experience:

Required: Bachelor's Degree Nursing, Healthcare management or related field And 5+ years Experience in an acute care setting.

PA RN License

Preferred: Master's Degree Nursing, Healthcare Management, or related field 1+ years Leadership experience

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

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