Chronic Disease Patient Navigator

Mass General Brigham; Somerville (MA); Hybrid; USD 50,000 - 85,000; Full time

Job summary

An established industry player is seeking a Chronic Disease Patient Navigator to enhance health outcomes for patients with chronic conditions like hypertension. This innovative role involves engaging with patients to identify their needs, providing education on self-management, and collaborating with healthcare teams to ensure quality care. The position is pivotal in promoting health equity and improving patient experiences. If you're passionate about making a difference in healthcare and possess strong interpersonal skills, this opportunity is perfect for you. Join a team dedicated to advancing community health and patient care!

Benefits

Health Insurance

Flexible Work Hours

Professional Development Opportunities

Paid Time Off

Retirement Plan

Wellness Programs

Qualifications

• 1-2 years experience in health navigation or related field preferred.
• Strong commitment to social justice and health equity.

Responsibilities

• Engage patients to set and achieve health goals.
• Review electronic medical records to obtain patient information.
• Generate reports and collaborate with care teams.

Skills

Health Coaching

Patient Advocacy

Motivational Interviewing

Data Management

Cultural Sensitivity

Communication Skills

Problem Solving

Organizational Skills

Education

Bachelor's Degree in Clinical Social Work

Healthcare Management

Tools

Electronic Health Records

Microsoft Office

Case Management Software

Job description

Chronic Disease Patient Navigator page is loaded

Chronic Disease Patient Navigator

Apply remote type Hybrid locations Somerville-MA time type Full time posted on Posted 6 Days Ago job requisition id RQ4016029 Site: Mass General Brigham Incorporated

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

MGB strives to advance health equity, improve health outcomes, and promote the well-being of our primary care patients by addressing health-related social needs, health system navigation, and care coordination as standard of care. Chronic Disease Navigators are an integral part of achieving these goals.

The Chronic Disease Navigator is an innovative role to help improve the health outcomes of patients in key conditions such as hypertension (high blood pressure). As a bridge between patients, providers, population health teams, and quality/health equity teams, a Navigator will support primary care practices in caring for panels of patients to improve quality outcomes related to chronic health needs, particularly hypertension.

By gathering and organizing patient data from clinical registries and medical records, the Navigator identifies patients’ unmet needs, engages patients in self-management (predominately telephonically), collects information for treatment interventions, and provides longitudinal reminders and support as patients work toward their health management goals.

While the Navigator is not a clinical position, it requires an ability to learn basic clinical concepts (for example, what high blood pressure is) and to understand when a referral to a licensed clinician is appropriate.

Principal Duties and Responsibilities

1. Patient Engagement and Coaching

• Build trust, identify barriers, and collaborate with patients and providers on setting and achieving health goals.
• Use motivational interviewing or similar techniques to support and encourage patients as they work to meet their chronic disease management goals.
• Deliver culturally sensitive education and guidance, assisting patients in self-care management.
• Support patients with attending appointments, coordinating follow-up appointments, and health related tasks between appointments, like taking home blood pressure readings.
• Create and support personalized health plans, and monitor progress to goals.
• Refer to patients to case management services, and advocate for access to programs when appropriate.
• Provide education to patients about the importance of lifestyle choices, medication adherence, and recommended screening guidelines as related to chronic disease management.

Data Review and Documentation

• Review electronic medical records to obtain relevant information on patients
• Utilize reports and registries to monitor patient quality metrics and address care gaps.
• Document patient encounters, track progress and goal completion.
• Generate mid-year and end-of-year reports, compiling data and providing case examples.

Collaboration

• Utilize reports and registries to monitor patient quality metrics and address care gaps.
• Provide coordination, and patient outreach as needed for specific target patient populations.
• Generate mid-year and end-of-year reports, compiling data and providing case examples. Collaborate with care teams to identify care plan goals and to support coordination of best practices for patient care.
• Foster relationships with appointment schedulers, collaborate with interpreters to reach patients who speak a preferred language other than English
• Maintain regular communication with the patient’s providers (through clinical messages in the electronic medical record, emails, phone calls, case review meetings, etc.), as appropriate

Qualifications

Education

• Bachelor's Degree in Clinical Social Work, Healthcare Management, or a Related Field of Study required

Experience

• 1-2 years experience in health navigation, health coaching, case management, or related field, ideally in a clinical setting preferred
• Experience working in a patient facing role or other customer facing role preferred.
• Prior use of electronic health records and other health care information systems helpful
• Strong commitment to social justice, health equity, and positively impacting the care of patients from all backgrounds.
• Proficient in Spanish, Haitian-Creole, or other languages is a plus but not required

Knowledge, Skills and Abilities

• Demonstrated ability to work effectively and provide advocacy for racial and ethnically diverse populations and communities
• Assessment and problem-solving skills
• Demonstrated organizational and time management skills
• Ability to develop effective relationships with a broad array of people from diverse backgrounds, including patients, families, clinicians, and other leaders
• Ability to interview patients using interactive techniques (e.g., motivational interviewing, active listening) to identify potential barriers to care
• Ability to work both independently and as part of a team in multicultural settings
• Strong oral and written communication skills
• Highly organized, proactive, and attentive to details
• Commitment to data accuracy and integrity
• Proficient in Microsoft Office applications, including Word and Excel
• Strong knowledge of healthcare resources, community services, and patient advocacy
• Excellent communication and interpersonal skills
• Ability to collaborate effectively with diverse healthcare professionals
• Familiarity with electronic health records and case management software

Additional Job Details

Remote Type: Hybrid

Work Location: 399 Revolution Drive

Scheduled Weekly Hours: 40

Employee Type: Regular

Work Shift: Day (United States of America)

EEO Statement: Mass General Brigham Incorporated 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. For accommodation requests, contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines effective leadership behaviors critical for success at each job level. It includes ten competencies, equally divided between People-Focused and Performance-Focused skills, which are used for performance evaluation, hiring, development, and talent pipeline development.

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