Transitions of Care Patient Navigator

Job Summary As an integral member of the Population Health Management Operations team, the Transitions of Care (TOC) Coordinator will support Medicare Shared Savings Program (MSSP) and Medicaid ACO patients as they transition from an inpatient hospital stay to their homes. In 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. Key Responsibilities Ensure patient discharge summaries are obtained, documented, and available in Epic by coordinating with hospitals, healthcare providers, and other relevant parties. Run daily reports to identify discharges, manage enrollment or closure of episodes, and confirm discharge documentation. Monitor and triage patient text message responses, escalating concerns to the appropriate team member. Coordinate and track follow‑up appointments and collaborate with practice staff to resolve scheduling barriers. Make outreach calls to patients for follow‑up care, appointment reminders, and to address care coordination needs. Assist patients with resource needs in the community, such as identifying transportation resources to ensure attendance at transitions of care appointments. Participate in team discussions to identify patient needs, elevate concerns, and ensure timely interventions. Identify opportunities to streamline workflows, enhance communication, and improve overall care coordination efficiency. Maintain a balance of operational efficiency while upholding the highest quality of patient care. Qualifications Bachelor's Degree in Healthcare Management or a related field of study required. Relevant experience can be accepted in lieu of a degree. 1+ year of case management, patient‑facing, medical office, or related clinical experience required. Epic experience preferred. Additional Knowledge, Skills and Abilities Strong knowledge of healthcare resources, community services, and patient advocacy. Excellent communication and interpersonal skills. Ability to collaborate effectively with healthcare professionals across multiple disciplines. Strong organizational and time‑management skills. Familiarity with electronic health records and case‑management software. Schedule and Work Model Full‑Time, Monday through Friday, standard business hours. Hybrid work model: mostly remote with a requirement to work in‑office at Assembly Row in Somerville, MA approximately once per month. On remote workdays, employees must use a stable, secure, compliant workstation in a quiet environment. Video conferencing is required and must be accessed using MGB‑provided equipment. Remote Type Hybrid Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $22.22 – $31.71 hourly EEO Statement 6010 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 Veteran’s 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 View phone number on click.appcast.io. #J-18808-Ljbffr Mass General Brigham