Population Health Transition Navigator

Site: Mass General Brigham Community Physicians Inc.

At Mass General Brigham we know it takes a surprising range of talented professionals to advance our missionfrom doctors nurses business people and tech experts to dedicated researchers and systems analysts. As a notforprofit organization Mass General Brigham is committed to supporting patient care research teaching and service to the community. We place great value on being a diverse equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.

At Mass General Brigham we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore we invite and welcome applicants from traditionally underrepresented groups in healthcare people of color people with disabilities LGBTQ community and/or gender expansive first and secondgeneration immigrants veterans and people from different socioeconomic backgrounds to apply.

Job Summary

The Population Health Transition Navigator is responsible for managing a patients successful transition from hospital to home and is accountable for developing implementing and evaluating comprehensive transitional care interventions for high risk medical surgical and/or trauma patients at MGB. They are responsible for managing the postacute care of highrisk patients that are at risk for poor health outcomes frequent emergency room visits and hospital readmissions and working with complex and varied patients and situations.

Duties:

• Navigates Epic reports and databases to identify patients for program enrollment

• Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning.

• Critically evaluates and analyzes physical and psychosocial assessment data.

• Interprets screening and selective laboratory/diagnostic tests.

• Initiates and maintains communication and collaboration with physicians social workers care team leaders staff nurses other care giving disciplines and patients/families to develop implement and evaluate a transition plan of care for each patient.

• Conducts a comprehensive patient/family assessment and transition/home care planning evaluation upon program enrollment to initiate and maintain the patients transitional plan of care.

• Monitors the achievement of clinical outcomes and communicates with inpatient teams primary and specialty physicians and staff regional providers and community resources (Home Health) regarding unanticipated variances.

• Assesses complexity of care needs and potential/actual issues or gaps in care.

• Arranges postdischarge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.

• Advocates for patients and families within the healthcare system with community providers and across the continuum of care.

• Identifies tracks and conducts root cause analyses on readmissions to address programmatic and systemwide improvements.

• Works with physicians providers researchers and postacute care leadership to identify broader system issues affecting patient care.

• Coordinates and facilitates patient progression throughout the continuum. Collaborates with all members of the healthcare team and external customers.

• Participates in clinical performance improvement activities to achieve set goals.

• Applies advanced critical thinking and conflict resolution skills using creative approaches.

• Supports postacute care leadership with systemlevel quality improvement.

Qualifications:

• Bachelors Degree and/or graduate of an accredited program related to licensure required

• Masters degree in a health carerelated field preferred

• OT PT PT Assistant (MA licensed) preferred

• ACMA certification as a case manager preferred

• Minimum 5 years experience including at least 2 years postacute care coordination and/or case management experience.

Skills and Abilities:

• Ability to establish strong rapport and relationships with patients and staff.

• Proficient in Microsoft Office and industry related software programs.

• Computer skills in word processing database management and spreadsheets.

• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

• Ability to maintain client and staff confidentiality.

Hybrid

399 Revolution Drive

40

Regular

Day (United States of America)

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.

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