Care Facilitator (Pride + Care Program)
About The Position
The Pride+ and HIV Care Facilitator is a member of a Pride+ Care Adult primary healthcare team and facilitates care for Reliant Medical Group’s LGBTQIA+ adult primary care patients. The facilitator coordinates accessible care plans, assesses for clinical triggers, and serves as a liaison among primary care teams, specialists, behavioral health team members, care management social workers, patients, and patients’ families. The role also supports patients living with HIV as HIV care at Reliant becomes more established. The facilitator builds longitudinal relationships with LGBTQIA+ patients, regularly assesses their clinical and social needs, and coordinates referrals to community support services aligned with patients’ identities and values. This includes maintaining an understanding of each patient’s identity, pronouns, preferred language, and cultural beliefs and values that may affect care, experience, or treatment recommendations. The role also manages data for the LGBTQIA+ patient population and conducts outreach for follow-ups, referrals, and specialized care needs. The facilitator enters standardized clinical and social information in administrative areas of patients’ care plans, collects data, generates reports, informs clinicians about assigned patients’ status, and may present performance metrics. The role attends specialty meetings and participates in care improvement activities, including ongoing training for care team and front-office staff. This is an onsite position in Worcester or Leominster, Massachusetts, with travel between sites and within the community and Massachusetts for events of up to 25%. The schedule is Monday through Friday between 8 a.m. and 6 p.m. EST, with the specific schedule determined by the supervisor upon hire.
Requirements
- High school diploma or GED.
- At least 1 year of experience working within a healthcare organization directly with patients.
- Proficiency in data management.
- Knowledge of medical terminology.
- Strong interpersonal and communication skills, with the ability to interact effectively with patients and medical professionals.
- Ability to demonstrate cultural competence and sensitivity to patient needs and concerns.
- Problem-solving skills.
- Self-starter.
Nice To Haves
- College degree in social work or population health management is strongly preferred.
- At least 1 year of EMR experience.
- Experience with referrals.
- Previous training or experience in population health management.
- Experience working with the LGBTQIA+ community in a facilitator or coordinator capacity and/or exposure to the local LGBTQIA+ ecosystem.
Responsibilities
- Serve as a primary point of contact for LGBTQIA+ patients, providing tailored support and guidance throughout their healthcare journey.
- Advocate for patients’ needs and rights within the healthcare system and help address barriers to care.
- Collaborate with primary care case management, internal and external specialists, nutrition, social work, and insurers as needed.
- Track patient adherence to scheduled appointments, labs, studies, referrals, and prescription recommendations.
- Manage the program referral work queue and help patients schedule primary care and Pride+ appointments.
- Contact patients, clinical and administrative staff, and external organizations to gather and relay clinical and care-plan information.
- Conduct frequent outreach calls, mailings, and MyHealth messages regarding lab tests, appointments, and chronic-care recommendations.
- Assess at-risk patients for clinical triggers that may require clinical intervention.
- Document outreach attempts in patients’ electronic medical records to support care coordination.
- Guide patients through care processes and transitions, provide directions, identify barriers and approaches, and facilitate specialty care needs.
- Support communication with clinicians and validate patient understanding.
- Collect feedback on the LGBTQIA+ Adult Medicine program and recommend continuous improvement.
- Maintain collaborative relationships with LGBTQIA+ community organizations, advocacy groups, and other stakeholders.
- Coordinate and lead monthly pilot panel roster reviews addressing chronic conditions and specialty needs.
- Attend care-navigation, organizational-update, and Pride+ Care meetings.
- Participate in community events, workshops, and e-learnings to promote the clinics and raise awareness about LGBTQIA+ health issues.
- Help patients enroll in medication assistance programs, including the Massachusetts HIV Drug Assistance Program (HDAP), and liaise among patients, care teams, and external programs.
- Help patients understand insurance coverage for primary care and Pride+ services, including gender-affirming care and injectable PrEP or HIV medication.
- Help patients navigate gender-affirming care, including identifying appropriate surgeons based on patient and insurance needs, coordinating with organizations and external referrals, and facilitating prior authorizations for some procedures.
- Perform other duties as assigned.
Benefits
- Paid time off accrued starting with the first pay period
- 8 paid holidays
- Medical plan options
- Health Spending Account or Health Savings Account
- Dental insurance
- Vision insurance
- Life and AD&D insurance
- Short-term disability coverage
- Long-term disability coverage
- 401(k) savings plan
- Employee Stock Purchase Plan
- Education reimbursement
- Employee discounts
- Employee Assistance Program
- Employee referral bonus program
- Voluntary benefits, including pet insurance, legal insurance, and long-term care insurance
- Performance rewards and incentive and recognition programs
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
