Job Description

The Nurse (RN) Health Navigator BPCI-A, under the direction of the Bundled Payments for Care Improvement Advanced (BPCI-A) Regional Manager, works in close collaboration with patients and their health care team to ensure that care coordination during transitions of care is efficient, effective, and patient-centered.


Identify, assess, plan, and implement comprehensive care plans for the identified patient population to meet the individual patient needs at the time of transitions in care.  Care planning to include determining appropriate discharge disposition, referrals, and coordination of post discharge services.


Collaborate with physicians, patients, families, and the multidisciplinary team in the acute care, rehab, skilled nursing facility, homecare, community, and physician practice setting to optimize quality and efficient outcomes.


Participate in regular team meetings, huddles, staff meetings, and quality improvement projects to improve patient care.  Ensure that hospital team is aware of BPCI-A requirements and assist leadership with decisions related to Bundles / Episode selection based on experience and trends.


Develop a comprehensive, collaborative care plan with input from the interdisciplinary team based on the provider treatment plan, evidence-based clinical care guidelines, and patient/family goals for patients in the BPCI-A program.


Assist with BPCI-A audits, chart reviews, and assures compliance with BPCI-A protocols.



Bachelor's degree required

Registered Nurse (RN) required

Certification in Case Management (CCM) strongly preferred

At least two (2) years of medical / surgical experience plus a minimum of two years of skilled nursing facility (SNF) experience

Experience in telephonic or onsite case management within home care setting, ambulatory, and/or skilled nursing setting

Experience developing care plans and monitoring patients across the care continuum

Possess strong clinical background in acute and post-acute care settings with focus on the delivery of high quality and cost effective care

Knowledge of Medicare, managed care principles, and physician practice

Proficiency in computer and technology utilization required, including but not limited to care management software, data-analytics software, Microsoft Office products (Outlook, Excel, PowerPoint, Visio)

Application Instructions

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