Transitions of Care Patient Navigator

Position Overview 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 their 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+ years of case management, patient‑facing, medical office, or related field experience, preferably in a clinical setting. 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 and experiences. 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 in‑office requirement at Assembly Row in Somerville, MA approximately once per month. On remote workdays, employees must use a stable, secure, and compliant workstation in a quiet environment. Teams Video is required and must be accessed using MGB‑provided equipment. 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. #J-18808-Ljbffr Mass General Brigham Community Physicians