RN – BreakThru Lead Nurse / CMS TEAM Program Nurse Navigator

Description

Job Title: RN – BreakThru Lead Nurse / CMS TEAM Program Nurse Navigator

Reports To: Chief Nursing Officer

Classification: Non-exempt

Job Summary:

This is a dual-role registered nurse position that serves two critical programs at Summit Surgical Hospital. In the first role, the incumbent serves as the Lead Nurse for BreakThru, Summit’s medically managed withdrawal program. In the second role, the incumbent functions as the Program Nurse Navigator for the CMS Transforming Episode Accountability Model (TEAM), supporting care coordination, quality outcomes, episode management, and compliance activities for qualifying surgical episodes under this mandatory Medicare bundled payment program.

Responsibilities:

BreakThru – Medically Managed Withdrawal Program (Lead RN)

• Serve as the primary clinical lead and point of contact for the BreakThru withdrawal management program.
• Conduct comprehensive nursing assessments for patients presenting with alcohol and/or drug withdrawal, including use of standardized assessment tools (e.g., CIWA-Ar, COWS).
• Collaborate with the multidisciplinary team—including physicians, pharmacists, social workers, and community partners—to deliver integrated, patient-centered care.
• Develop, coordinate, and document individualized aftercare and discharge plans in partnership with community referral organizations.
• Conduct patient follow-up at one, three, six, and twelve-month intervals to assess remission, sobriety, and engagement in ongoing treatment.
• Educate patients, families, and staff on substance use disorders, withdrawal management, and recovery resources.
• Maintain program data and support quality improvement initiatives to measure patient outcomes and program effectiveness.
• Ensure patient dignity, confidentiality, and compliance with all applicable regulatory and HIPAA requirements throughout the episode of care.
• Establish and maintain relationships with community referral partners to facilitate seamless transitions of care.

CMS TEAM – Program Nurse Navigator

• Serve as the nurse navigator for Summit Surgical’s CMS Transforming Episode Accountability Model (TEAM) program, supporting compliance with mandatory bundled payment episode requirements.
• Identify and track qualifying TEAM surgical episode patients across the episode of care, from pre-operative preparation through the 90-day post-discharge period.
• Coordinate care transitions and communicate with patients, families, and post-acute care providers to reduce unnecessary readmissions and complications.
• Conduct post-discharge patient outreach and follow-up to assess recovery, address care gaps, and connect patients with appropriate resources.
• Collaborate with surgeons, hospitalists, case managers, and the quality team to optimize clinical and financial performance within episode benchmarks.
• Assist in collection, review, and submission of quality measure data required by CMS for the TEAM model.
• Maintain accurate and timely documentation of navigation activities, care coordination contacts, and patient outcomes in the electronic health record.
• Participate in TEAM performance reporting, variance analysis, and quality improvement efforts to achieve program goals.
• Serve as an internal resource and educator for clinical staff regarding TEAM model requirements, patient eligibility, and episode management best practices.
• Liaise with post-acute care facilities, home health agencies, and community providers to ensure continuity of care for TEAM episode patients.

Requirements

Qualifications:

Education: Associate’s Degree in Nursing (ADN) required; Bachelor of Science in Nursing (BSN) preferred.

Licensure: Current, active Registered Nurse (RN) license in the State of Kansas, or eligible for licensure by endorsement.

Certification: Basic Life Support (BLS) required. Advanced Cardiac Life Support (ACLS) preferred. Certified Addictions Registered Nurse (CARN) or similar certification is a plus.

Experience: Minimum of two (2) years of clinical nursing experience required. Experience in medical/surgical, behavioral health, substance use treatment, or care coordination strongly preferred.

Skills:

Knowledge of substance use disorders, withdrawal physiology, and evidence-based withdrawal management protocols.

Familiarity with or ability to quickly learn CMS bundled payment models, value-based care concepts, and care coordination methodologies.

Strong clinical assessment, critical thinking, and clinical decision-making skills.

Excellent interpersonal, communication, and