Emerging Risk Patient Navigator Care Coordinator

Mass General Brigham•Somerville, MA

1d•$22 - $32•Hybrid

About The Position

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. 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).

Requirements

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.

Nice To Haves

Knowledge of Social Determinants of Health (SDOH) strongly preferred.
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.

Responsibilities

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