Regional Complex Care Coordinator

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.

 

Regional, Complex Care Coordinator, Multiple Locations

The Integrated Care Management Program (iCMP) supports and coordinates health care for primary care patients with complex health issues.

Population Health Services Organization vision is to enable health care providers and patients in our Accountable Care Organization to achieve the best outcomes in the nation.

Multi Regional locations are hiring Care Coordinators to support regional community practices and patients. Weekly onsite travel to work onsite with patients and their care team, will include Somerville and Community Practices in assigned regions; Boston and surrounding, Metro Boston, Boston proper, North Shore, South Shore, Metro West and possible New Hampshire sites if assigned to North Shore, MA. MGB local sites and primary sites are a wonderful meeting place for patients and their Care Coordinator.

 

Job Summary

The Opportunity

As part of The Integrated Care Management Program (iCMP), You will support and coordinates health care for primary care patients with complex health issues.

Our team’s guiding principles are to:
• Keep patients healthy and at home as long as possible
• Better understand our patients’ health needs to guide timely and effective care
• Use performance and benchmark data to identify and act on opportunities for improvement
• Strengthen our performance in risk contracts so we can reinvest in our patients by partnering with providers across our hospitals and clinics to develop impactful interventions


The Complex Care Coordinator is vital to the multi-disciplinary team of clinicians serving MGB’s highest risk patients. The Complex Care Coordinator will coordinate all non-clinical patient needs, help with the connection to the primary care offices and support the patients to achieve their care goals by helping them connect to community resources and services, address social barriers and support patients through reminders and education reinforcement.

Responsible for working closely with patients, families, and healthcare providers to ensure a seamless and patient-centered care experience. Assist with navigating the complexities of the healthcare system, coordinating resources, and providing support to improve patient outcomes.

What You'll Do

• Advocate for patients and their families, ensuring their needs and preferences are considered in the care planning process.
• Serve as a liaison between patients, healthcare providers, and other relevant stakeholders.
• Collaborate with the interdisciplinary healthcare team to coordinate patient care services, appointments, and follow-up plans.
• Assist patients in understanding and adhering to their care plans.
• Identify and connect patients with appropriate healthcare and community resources, such as support groups, financial assistance programs, and transportation services.
• Educate patients and their families about their medical conditions, treatment options, and self-care strategies.
• Ensure that patients are informed and empowered to actively participate in their healthcare decisions.
• Maintain accurate and detailed documentation of patient interactions, care plans, and resource referrals

 

Qualifications

What You'll Bring

• Bachelor's Degree in a health-related field, public health, or human services field required.
• Minimum one year experience in care coordination, population health, or a related healthcare role.  Internship or other transferable experience will be accepted.
• Experience in navigating healthcare systems, patient advocacy, and understanding of medical/social services.

Skills & Abilities for Success

• Experience documenting in Electronic Health Records, scheduling platforms, and data tracking tools.
• Prior experience in managed care, care management, or hospital-based care coordination.
• Bilingual or multilingual ability is a plus, especially in languages relevant to the patient population such as Spanish, Portuguese, and Haitian-Creole.
• Excellent communication and interpersonal skills.
• Ability to collaborate effectively with healthcare professionals across multiple disciplines and experiences.
• Exceptional organizational