Transitions of Care Coordinator Patient Navigator

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

As an integral member of the Population Health Management Operations team the Transitions of Care (TOC) Coordinator Patient Navigator will support Medicare Shared Savings Program (MSSP) and Medicaid ACO patients as they transition from an inpatient hospital stay to their this role the Coordinator will work closely with a team of nurses and a pharmacist to facilitate care coordination ensure timely access to discharge information and support patients in navigating follow-up needs.

Job Summary

The Transitions of Care Coordinator is vital to the multi-disciplinary team of clinicians serving MGBs highest risk patients. The teammate will coordinate all non-clinical patient needs help with the connection to the primary care offices and support the patients to achieve their care goals by helping them connect to community resources and services address social barriers and support patients through reminders and education reinforcement.

Responsible for working closely with patients families and healthcare providers to ensure a seamless and patient-centered care experience. Assist with navigating the complexities of the healthcare system coordinating resources and providing support to improve patient outcomes.

Role Duties

Advocate for patients and their families ensuring their needs and preferences are considered in the care planning process.
Serve as a liaison between patients healthcare providers and other relevant stakeholders.
Collaborate with the interdisciplinary healthcare team to coordinate patient care services appointments and follow-up plans.
Assist patients in understanding and adhering to their care plans.
Identify and connect patients with appropriate healthcare and community resources such as support groups financial assistance programs and transportation services.
Educate patients and their families about their medical conditions treatment options and self-care strategies.
Ensure that patients are informed and empowered to actively participate in their healthcare decisions.
Maintain accurate and detailed documentation of patient interactions care plans and resource referrals

What Youll Bring

Requirements

• High School Diploma or GED required. Bachelors Degree or equivalent work experience strongly preferred.
• Experience in care coordination population health or a related healthcare or other transferable experience will be accepted.
• Experience documenting in Electronic Health Records scheduling platforms and data tracking tools. Ideally Epic.

Preferences

• Experience in care coordination patient navigation or healthcare support role.
• Experience in navigating healthcare systems patient advocacy and understanding of medical/social services.
• Knowledge of hospital or healthcare systems.
• Ability to start at 7:30am.
• Prior experience in managed care care management or hospital-based care coordination.
• Bilingual or multilingual ability especially in languages relevant to the patient population such as Spanish Portuguese and Haitian-Creole.

Skills for Success

• Excellent communication and interpersonal skills.
• Ability to collaborate effectively with healthcare professionals across multiple disciplines and experiences.
• Strong organizational and time management skills.
• Strong ability to work autonomously while supporting a multidisciplinary team.

Schedule and Working Model

• 40 hours Monday through Friday Eastern Business Hours. Preferably with the ability to start at 7:30am.
• Remote positionrequires stable secure quiet compliant working area free from distraction and HIPAA compliant.

Remote

399 Revolution Drive

40

Regular

Day (United States of America)

Pay Range

$21.78 - $31.08/Hourly

Grade

5

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 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.

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 Veterans 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 .

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