Advanced Practice Provider Pre Post Surgical Optimization

Mass General Brigham Community Physicians
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jul 18, 2025
The Nurse Practitioner (NP) is a licensed provider. The NP is responsible for the assessment and management of various populations of patients, medical and/or surgical, including diagnostic and therapeutic interventions, development of appropriate plans of care and ongoing evaluation. This APP will focus on pre- and post-surgical optimization. The APP will lead 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 will see patients both virtually and in-person and will work closely with the multidisciplinary team to develop patient optimization programs throughout the course of the episode. The APP focuses primarily on the following areas: pre-operative optimization, risk capture and risk assessment, and closure of quality care gaps. What You'll Bring Master's Degree Nursing required Registered Nurse [RN - MA State License required] Preferred Nurse Practitioner [NP] / Advanced Practice Registered Nurse [APRN] [MA State License] Experience as a nurse practitioner 0-1 year preferred Physician Assistant candidate can also be considered, MA state license required Master's Degree Physician Assistant required Physician Assistant [State License] Experience as a licensed Physician Assistant preferred The PHSO with stakeholders across Mass General Brigham is developing standard, patient-centered episodic operational pathways and workflows to support care delivery and outcomes. Program development is informed by evidence-based learnings and best practices. Program goals include mitigation of risk, patient optimization, reduced length of stay as appropriate throughout the pathway, continuity of care and positive long-term health outcomes. The APP will be responsible for perioperative optimization and supporting non-clinical coordinators in navigating patients through the care journey. Clinical oversight and insight Serve as a clinical practitioner for the multidisciplinary CMS TEAM program team Provide clinical oversight of day-to-day team functions (including refinement of protocols, procedures and policies). Provide both virtual and in-person direct patient care and education to patients undergoing one of the surgical procedures included in the CMS TEAM model Provide support for all clinical needs of the multidisciplinary CMS TEAM program team Serve as escalation pathway for CMS TEAM coordinators Assist CMS TEAM in development and optimization of care pathways, perform PDSA and other process improvement tools Clinical Responsibilities Pre-operative Optimization for CMS TEAM pathways Conduct pre-op optimization screen related to mobility, frailty and support at home Create pre-op plan in coordination with the primary clinical team who conducts pre-operative visit Drive early patient engagement to support safe discharge Place lab, and DME orders as indicated for CMS TEAM pathways Enter referrals for imaging as indicated for CMS TEAM pathways Enter referral to specialists as indicated for CMS 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 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 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. Intra-visit Patient Care Provide information, education, and support to patients and families and includes them in planning discussions, with a focus on discharge home and outpatient surgery support as appropriate Respond to ongoing patient questions Manage additional referrals and pre-op optimization needs Conduct follow-up engagement as indicated Provide supportive materials for insurance inquiries 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 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 CMS 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. This will be a hybrid role starting with a minimum of 3 days in-person per week at sites to be determined. 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. Skills for Success 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. Locations M-F Eastern Business Hours required BWH and MGH Ambulatory sites Must be flexible for 3-5x onsite weekly Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.