Emerging Risk Patient Navigator Care Coordinator

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. Job Summary The Patient Navigator is responsible for working closely with patients, families, and healthcare providers to ensure a seamless and patient-centered care experience by assisting with navigating the complexities of the healthcare system, coordinating resources, and providing support to improve patient outcomes. Primary Responsibilities: The Patient Navigator is a non-clinical healthcare professional with a bachelor’s degree in a health-related or social services field, serving as a critical support member of the Emerging Risk Program, a component of the CARE Compass program. The Patient Navigator is a member of an interdisciplinary team that supports patient centered care coordination for individuals identified as “rising risk” based on medical conditions, Social Determinant of Health (SDOH) needs and an inflection in utilization patterns. This team member works closely with healthcare providers to ensure that patients receive appropriate care and support services to improve health outcomes. The Patient Navigator in the Emerging Risk Program is flexible and can adapt to an ever-changing health care environment. This role requires willingness to assess, participate in ongoing process improvement activities and innovate processes and workflows to support time limited targeted care coordination. This role will utilize a variety of intervention modes including but not limited to video, telephone and patient gateway (MGB Patient Portal). What You'll Do • Conduct telephone outreach to patients to complete a needs assessment with a focus on identifying opportunities to improve patient health outcomes. • Based on a needs assessment, work with patients to identify patient centered goals with a focus on SDOH needs and provide time limited support to assist patients towards achievement of goals. • Act as a content expert for SDOH resources and services patients can access in the community including, but not limited to, supports for patients with food insecurity, housing insecurity, transportation barriers, and financial barriers. • Provide limited, focused coaching and motivational interviewing to patients and caregivers to educate and empower SDOH stability goals. • Utilizing stratification tools, identify and refer patients to the Emerging Risk RN for patients that need additional clinical assessment and support for disease management. • Maintain compliance with MGB and PHSO care coordination documentation standards, maintaining accurate and timely patient records. Maintain appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours as per CARE Compass Program standards • Ensure adherence to case management standards and payor contract requirements as appropriate to scope and role. Participate in program evaluations and continuous quality improvement efforts to enhance patient outcomes and program effectiveness • Support patients in navigating insurance benefits and community resources. This may include connecting patients with payor experts for medications, home care, and specialty services and assist and empower patients/families in coordination of benefits. Identify financial assistance programs to ensure patients have access to cost-support Qualifications Qualifications: Bachelor's Degree in Healthcare Management or related field of study required. Related experience can be considered in lieu of a degree. 1+ year of social work, case management or related experience required, preferably in a clinical setting. Strong knowledge of healthcare resources, community services, and patient advocacy required. Strong organizational and time management skills required. Knowledge of Social Determinants of Health (SDOH) strongly preferred. Additional Skills for Success: 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. Additional Job Details (if applicable) Schedule and Work Model: Full time, Monday through Friday, approximately 8am-4:30pm ET Work Model: Primarily remote / work from home with occasional meetings and training at Assembly Row in Somerville, MA. Remote workdays require stable, secure, quiet, compliant workstation using MGB issued 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 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 package. In 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. 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. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Combat disease. Hold a hand. Help people. Impact the world. Mass General Brigham is a passionate, welcoming community where minds meet caring hearts. Come be a part of the world’s most powerful force in medicine, where every role is important in changing lives. Are you ready? Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world. Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence.