Site: Mass General Brigham Community Physicians, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

The Opportunity:

The APP will join a multidisciplinary team dedicated to provision of innovative, patient-centered care as part of the CMS Transforming Episode Accountability Model (TEAM). This is a mandatory, episode-based, alternative payment model, in which Mass General Brigham will coordinate optimal care for traditional Medicare patients undergoing one of five specified surgical procedures and assume responsibility for the cost and quality of care from surgery through the first 30 days after the patient leaves the hospital.

This model aims to improve the patient experience preoperatively, through surgery and recovery. This will be done by supporting the coordination and transition of care between providers and promoting a successful recovery that can reduce unnecessary post-acute care utilization and readmissions.

This role is designed to proactively assess and support these patients through the full journey of the surgical episode (pre-surgery, in-facility surgery, post-surgery). The APP is responsible for medium- and high-risk pre-operative optimization and provides direct patient care both in-person and virtually. They will work closely with the multidisciplinary team to support patient optimization throughout the course of the episode.

The APP also conducts risk capture and risk assessment, as well as closure of quality care gaps.

Job Summary:

Key Responsibilities:

-Seek and maintain personal knowledge regarding perioperative optimization and associated problems to provide accurate resource information to patients
-Maintain clinical competency, professional skills, and knowledge through experiences and formal continuing education programs and independent learning activities
-Responsible for maintenance of all certifications/licensures required to fulfill duties of the position.
-Willingness to collaborate with hospital colleagues and outside healthcare resources are essential
-Foster communication between TEAM program staff and other health care team members
-Participates in the assessment, development, implementation, and evaluation of quality improvement programs, standards of practice, and policies and procedures.
-Fulfill duties to ensure seamless patient care as requested by medical director
-Other Administrative Duties: as necessitated by program development and at the direction of leadership.

Clinical Care

-Provide both virtual and in-person direct patient care and education to TEAM patients
-Provide support for all clinical needs of the multidisciplinary TEAM program team
-Conduct comprehensive pre-operative geriatric assessments and pre-op optimization screen related to mobility, frailty and support at home
-Place lab, and DME orders as indicated for TEAM pathways
-Enter referrals for imaging as indicated for TEAM pathways
-Enter referral to specialists as indicated for TEAM pathways
-Document assessment data, orders, interventions, results and evaluations within the patient's medical record per established standards
-Documentation is consistently complete, accurate, timely and legible in accordance with departmental policies and procedures
-Drive early patient engagement to support safe discharge

Care Coordination and Escalation:

-Provide clinical oversight of day-to-day team functions (including refinement of protocols, procedures and policies)
-Serve as escalation pathway for CMS TEAM coordinators and PT Navigators
-Collaborate with local surgical or inpatient teams as indicated
-Assist in development and optimization of care pathways, perform PDSA and other process improvement tools

Intra-visit and Post-operative Patient Care and Support:

-Provide information, education, and support to patients and families; include them in planning discussions, with a focus on discharge home
-Respond to ongoing patient questions
-Manage additional referrals and pre-op optimization needs
-Conduct follow-up engagement as indicated
-Elicit goals and values from patients and families to better guide them in care plans
-Answers telephone calls/messages from patients, family members and clinical staff

Documentation and Risk Capture:

-Complete review and documentation of patient conditions in alignment with PHSO risk capture team
-Use standardized tools for risk/ discharge destination
-Bill for activities via required billing pathway
-Compliance with MGB billing standards

Qualifications:

What You'll Bring:

Qualifications:

• Advanced Practice Registered Nurse (APRN-NP) or Physician Assistant (PA) licensure required

• More than 2 years of licensed experience required.

• Experience in perioperative medicine and/or geriatrics preferred.

Additional Knowledge, Skills and Abilities:

• Skilled in taking medical histories to assess medical condition and interpret findings.

• Ability to maintain quality control standards.

• Ability to react calmly and effectively in emergency situations.

• Ability to interpret, adapt and apply guidelines and procedures.

• Ability to communicate clearly and establish/maintain effective working relationships with patients, medical staff and the public.

• BLS required (or secured within the first 3 months of employment)

al issues efficiently and effectively with minimal supervision

Additional Job Details (if applicable)

Schedule and Work Model

• Full time, Monday through Friday, standard business hours.

• This will be a hybrid role starting with a minimum of 3 days in-person per week at on-site.

• Anticipated Schedule:

• Monday and Friday on-site at Mass General Hospital.

• Tuesday WAH administrative day / every other Tuesday on-site at Assembly Row in Somerville, MA.

• Wednesday WAH / virtual visits.

• Thursday on-site at Newton Wellesley Hospital.

Remote Type

Hybrid

Work Location

399 Revolution Drive

Scheduled Weekly Hours:

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$122,803.20 - $173,867.20/Annual

Grade

7

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.