Patient Liaison - Dorchester

Description

What is this role about?

Our older adult patients living in communities that we serve are faced with a variety of social challenges, called “Social Determinants of Health”, or SDOH. Internally called “Gather Guide Partner”, this individual will work closely with our patients to identify their needs, researching solutions that address various barriers, and ultimately enabling them to gain access to critical resources. These challenges include things such as food insecurity, social isolation and loneliness, lack of transportation, etc. The Gather Guide Partner (GGP) will get to know our patients and their unique situations such that they will become the trusted and consistent point-of-contact for them.

The GGP will work collaboratively with our primary care providers, Medical Technician Partners (EMTs), and clinic administrators, as part of the care-team model. This partnership allows us to care for the “whole” patient, rather than only focusing on their physical health. Because of this, the GGP plays a significant role in our ability to provide the best care and support possible with a deep sense of commitment and compassion – and ultimately achieve our vision of creating equity in healthcare.

What are some of the day-to-day duties?

The day-in-the-life of a GGP will vary, depending on the needs of our patients. The majority of your time will be spent in your designated clinic, where you will interact with our patients face-to-face as well as over the phone, virtual visits, etc. Some of the day-to-day duties will include but are not limited to:

· Conduct a face-to-face screening with new patients to identify their individual social needs and document notes

· Ensure social re-screenings are completed for existing patients at least once yearly (In clinic or over the phone)

· Collaborate with the patient and care team to develop personalized social care plans for each patient

· Follow up with patients considered to be high ER/Hospital utilizers to check in on health status after an ER or Hospital admission

· Check in regularly with patients struggling with both health and severe SDOH concerns

· Facilitate Durable Medical Equipment coordination

· Answer inbound clinic calls to provide high level and customized service

· Complete administrative tasks related to SDOH or DME needs

· Research various resources available in the community that are relevant to the needs of our patients

· Continuously expand our network of resources to address gaps such as transportation, food, activities, social connections, and other social determinants of health

· Facilitate patient group activities in our common social events space

· Identify and facilitate creative methods for providing individualized support for patients in need

What are the minimum requirements for this position?

· Minimum of one year of experience working in medical settings, community-based organizations, hospitality, or other related service industries

· Experience working one-on-one with patients and/or customers

· Experience working in roles that required frequent communication on the phone and in-person

· Experience with basic office tools such as email, Outlook calendar, etc.

· Strong verbal, written, and reading comprehension skills in English

· Ability to work regular office hours Monday through Friday

· Ability to work for any employer in the United States

What are the “nice to have”, preferred requirements?

· Experience working with seniors or individuals with complex social needs

· Experience working in a primary care office

· Associates or bachelor’s degree

· Experience as a birth or end-of-life doula

· Bilingual English & Vietnamese

What are the traits of someone most likely to succeed in this role?

· Compassionate – they treat people with kindness

· Patient – they are not easily frustrated or flustered

· Nonjudgmental – they tend to give others the benefit of the doubt

· Understanding – they “get” that everyone has their unique struggles

· Helpful – they get their fulfillment by adding value to other people’s lives

· Friendly – people enjoy their company

· Outgoing – they tend to enjoy mingling with others and getting to know new people

· Relatable – naturally makes human connections with their warmth, humor, and demeanor

· Positive – sees glass as is half full vs. half empty

· Flexible – can easily pivot based on business needs

· Dedicated – committed to serving others

· Organized – manages time effectively and operates efficiently

· Reliable – takes responsibilities seriously and always shows up on time

What are the hours for this position?

Monday – Friday during standard business hours

Who is Gather Health?

Gather Health delivers Social Primary Care to older adults. Through our unique and differentiated care model and proprietary technology, Gather Health’s solution drives substantial care outcomes by addressing the whole person needs of our target demographic: older, dual eligible adults, the fastest growing government segment. To address the needs of these clinically and socially complex patients, Gather Health’s Social Primary Care solution is comprehensive and wholistic in nature, encompassing care and community within the four walls of Gather Health Centers and in the homes of its patients.

Gather’s model achieves superior care by individualizing care and is reinforced by a three-prong approach: a unique care model quarterbacked by PCPs and supported by multi-disciplinary care teams, tailored Social Care Plans that are led by Gather Guides and facilitated by deeply rooted community partners, and a proprietary “Tech Enabled Home Model.”

Founded in 2022 and born out of the Healthcare Foundry Portfolio, Gather Health is addressing a $1 trillion market in primary care for older adults. Today, Gather Health operates in Massachusetts and is working with a multitude of payer partners on aligning value-based care economics to deliver integrated care. Gather’s leadership team has a track record of building and scaling innovative primary care platforms focused on vulnerable populations, including VillageMD and Commonwealth Care Alliance. Gather has raised $30M backed by Maverick Ventures, Khosla, and HC9 Ventures.

We are committed to supporting every aspect of your life by offering a total rewards package designed to support your health, financial security, and work-life balance:

• Health: Comprehensive medical, dental, and vision with day-one eligibility
• Protection: Company-paid Life, Short-Term, and Long-Term Disability insurance
• Retirement: 401(k) with company match and immediate vesting
• Time Off: Generous PTO that increases with tenure and 11 paid company holidays
• Wellness: Employee Assistance Program (EAP) and supplemental benefit options