Transitions of Care Patient Navigator
Job Description
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
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 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.
Qualifications
Qualifications:
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.
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.
Additional Job Details (if applicable)
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.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$22.22 - $31.71/Hourly
Grade
5
EEO Statement:
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.