Population Health Transition Navigator

Mass General Brigham Community Physicians; Somerville (MA); On-site; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated Population Health Transition Navigator to ensure patients transition smoothly from hospital to home. This role involves managing high-risk patients, coordinating care, and advocating for patients across the healthcare system. The ideal candidate will possess strong communication skills and critical thinking abilities, working closely with a diverse team to improve patient outcomes. Join a forward-thinking organization committed to quality care and make a significant impact on patient health and community well-being.

Qualifications

• Minimum 5 years' experience in post-acute care coordination.
• Bachelor's Degree or related licensure required.

Responsibilities

• Manage patient's transition from hospital to home.
• Communicate with healthcare teams to develop care plans.

Skills

Patient Advocacy

Care Coordination

Critical Thinking

Problem Solving

Communication Skills

Education

Bachelor's Degree

Master's Degree in Health Care

ACMA Certification

Tools

Microsoft Office

Epic Systems

Job description

The Population Health Transition Navigator is responsible for managing a patient's successful transition from hospital to home. They develop, implement, and evaluate comprehensive transitional care interventions for high-risk medical, surgical, and trauma patients at MGB. They manage post-acute care for patients at risk for poor health outcomes, frequent ER visits, and readmissions, working with complex cases and varied situations.

Duties:

1. Navigates Epic reports and databases to identify patients for program enrollment.
2. Identifies patient/family education needs and ensures they have adequate information for transition planning.
3. Evaluates physical and psychosocial assessment data critically.
4. Interprets screening and diagnostic tests.
5. Communicates and collaborates with physicians, social workers, care team leaders, nurses, and families to develop and evaluate care transition plans.
6. Conducts comprehensive assessments upon enrollment to initiate and maintain the patient's transition plan.
7. Monitors clinical outcomes and communicates with inpatient teams, physicians, and community resources regarding variances.
8. Assesses care needs and identifies care gaps or issues.
9. Arranges post-discharge referrals for further evaluation or services.
10. Advocates for patients and families across the healthcare system and community providers.
11. Tracks and analyzes readmissions to improve system-wide processes.
12. Works with healthcare leaders to identify systemic issues affecting care.
13. Coordinates patient progression and collaborates with healthcare team and external partners.
14. Participates in quality improvement activities.
15. Uses advanced critical thinking and conflict resolution skills.
16. Supports system-level quality initiatives within post-acute care.

Qualifications:

• Bachelor's Degree or related licensure required.
• Master's degree in a health care-related field preferred.
• OT, PT, PT Assistant (MA licensed) preferred.
• ACMA certification as a case manager preferred.
• Minimum 5 years' experience, including at least 2 years in post-acute care coordination or case management.

Skills and Abilities:

• Ability to establish rapport with patients and staff.
• Proficient in Microsoft Office and related software.
• Skilled in word processing, database management, and spreadsheets.
• Capable of problem-solving and developing solutions.
• Maintains confidentiality of client and staff information.

Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. We embrace diversity and are committed to providing accommodations for individuals with disabilities throughout the application and employment process.