Transitions of Care Patient Navigator

Site: Mass General Brigham Community Physicians, Inc.

 

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:

• 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.

 

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.

 

Hybrid

 

399 Revolution Drive

 

40

 

Regular

 

Day (United States of America)

 

Pay Range

$22.22 - $31.71/Hourly

 

Grade

5

 

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

 

6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

 

Mass General Brigham Competency Framework