Chronic Care Navigator & Patient Advocate

Baystate Health; Springfield (MA); Hybrid; USD 35,000 - 47,000; Full time

Job summary

HNE BeHealthy ACO is seeking a Care Coordinator in Springfield, MA to support high-quality, cost-effective care for patients with chronic illnesses and complex social needs. You will act as a liaison among patients, families, providers, payers, and community resources to promote engagement, self-management and continuity of care.

The role involves coordinating referrals, transitions of care, and follow-up while collaborating with the interdisciplinary team.

Qualifications

• 2–5 years of experience in a medical or healthcare setting.
• Experience working with diverse populations and individuals with complex medical and social needs.
• Strong organizational, communication, documentation, and computer skills.
• Ability to work independently and collaboratively as part of an interdisciplinary team.
• Strong patient advocacy and care coordination skills.

Responsibilities

• Serve as a resource, advocate, and point of contact for patients, families, providers, payers, and community resources.
• Coordinate referrals, transitions of care, follow-up, and access to appropriate healthcare and community services.
• Collaborate with the Nurse Care Manager, providers, behavioral health, and other members of the interdisciplinary team to support comprehensive patient care.
• Review care plans with patients and families, monitor progress, and identify barriers to achieving care goals.
• Promote preventive care, self-management, and shared decision-making while helping reduce avoidable ER visits and hospitalizations.
• Maintain accurate and timely documentation in the medical record and track referrals, patient contacts, and follow-up needs.
• Collect and enter data to support program reporting, quality improvement, and evaluation.
• Utilize clinical, research, and quality databases as appropriate.
• Work independently while maintaining strong communication and collaboration with the healthcare team.
• May conduct home visits as needed.

Skills

Organizational skills

Communication skills

Documentation

Computer skills

Care coordination

Education

High School Diploma

Job description

HNE BeHealthy ACO is seeking a Care Coordinator in Springfield, MA to support high-quality, cost-effective care for patients with chronic illnesses and complex social needs. You will act as a liaison among patients, families, providers, payers, and community resources to promote engagement, self-management and continuity of care.

The role involves coordinating referrals, transitions of care, and follow-up while collaborating with the interdisciplinary team.