Transitions of Care Patient Navigator

Mass General Brigham•Somerville, MA

1d•$22 - $32•Hybrid

About The Position

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.

Requirements

Bachelor's Degree Healthcare Management or other related field of study required. Relevant experience can be accepted in lieu of degree.
1+ years case management, patient facing, medical office or related field, preferably in a clinical setting required.
Epic experience preferred.
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.

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 patient’s community such as identifying transportation resources to ensure attendance at transitions of care appointments.
Participate in team discussions to identify patient needs, escalate 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.