New

Physical Therapy Navigator Pre/Post Surgical Optimization

Mass General Brigham Community Physicians
remote work
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Aug 13, 2025
The Opportunity This is an exciting opportunity to join the Mass General Brigham Population Health Services Organization (PHSO) as a Physical Therapy Navigator (PTN) focused on optimization of specific surgical episodes and outcomes. The Physical Therapy Navigator will be part of a multidisciplinary team dedicated to provision of innovative, patient-centered care as part of the CMS Transforming Episode Accountability Model (TEAM). The PTN will assist with the coordination of care for TEAM patients, with the goal of facilitating an expected course of care from the pre-op phase through the post-acute care phase. The Physical Therapy Navigator PTN will be responsible for the pre-operative clinical, functional, and social assessment utilizing the Risk Assessment and Prediction Tool (RAPT) and other assessment tools as indicated to ensure appropriate care pathway allocation. The PTN will collect, synthesize, and interpret data from established screening tools and outcome measures via virtual outreach. The PTN will collaborate with patients, provider offices, and other members of the healthcare team on the episode of care. The PTN will also collaborate with post-acute care providers (extended care facilities and home health services) on both projected and desired promotion of care plans in the post-acute phase. Will be part of a multidisciplinary team dedicated to improving the patient experience preoperatively, through surgery and recovery at home. 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. Will assist with the coordination of care for the identified surgical patients, with the goal of facilitating an expected course of care from the pre-op phase through the post-acute care phase. Responsible for the pre-operative clinical, functional, and social assessment utilizing the Risk Assessment and Prediction Tool (RAPT) to ensure appropriate care pathway allocation. Will collect, synthesize, and interpret data from established screening tools and outcome measures. Will collaborate with patients, provider offices, and other members of the healthcare team on the episode of care. The Physical Therapy Navigator will also collaborate with post-acute care providers (extended care facilities and home health services) on both projected and desired promotion of care plans in the post-acute phase. Establishes therapy goals and formulates a treatment plan based on evaluation results after thorough Virtual Evaluation of home Provide initial assessment of clinical needs using standardized tools and protocols and facilitate recommendations for treatment. Record all pertinent data in the patient's medical records What You'll Bring Doctor of Physical Therapy highly preferred Physical Therapist [MA State License] required Experience in an inpatient hospital setting, at least 5 years required Excellent interpersonal skills required. Ability to work independently with only general supervision. Exceptional attention to detail and ability to multitask. Ability to lead and accomplish tasks with a team Exceptional verbal and written communication skills. Excellent coach and strong motivator. Excellent problem solving, case management and communication skills. Skills For Success Strong understanding of Physical Therapy strategy, progressive mobility, goals for early surgery recovery Excellent communication with patients, families, healthcare providers Desire to help elder populations through complex medical procedures and recovery Ability to build relationships in a multi-disciplinary team spread across multiple facilities, liaise with physician offices, health care teams, external agencies, patients + families Strong critical thinking to help identify key patient barriers for home recovery (home assessment, social and functional barriers) Proactive approach with respect to problem-solving and issue escalation Strong use of electronic medical record and digital tools Use of clear documentation and data collection best practices Ability to synthesize information and data into clear patient risk assessment (RAPT, FRAIL, chart review) We are looking for passionate PTN with a desire to work with geriatric patient population, a desire to help support pre and post op surgical needs for patient to be successful at home. This team is expanding, we are innovative to support patients and provide home assessment virtually. The team program and model is being built out, goal is focused on progressive mobility for patient recovery at home. The PTN will be working hand in hand with APP and supported with various members of team to provide the best possible outcome plan for patient success. Working Model/Location:* Hybrid (planned onsite monthly at Assembly Row) Estimated 2-4 days monthly onsite, includes every other Tuesday, with some exceptions due to holiday cadence or other events. Remote work requires stable, secure, compliant quiet working station Virtual care model for thorough Virtual Home Assessment Must be flexible for training onsite as program expands, business needs will vary 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.