Patient Navigator, Ambulatory Safety Net (Hybrid)
Mass General Brigham(PHS)

Job Info

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About Us

As a not-for-profit organization, Partners HealthCare is committed to supporting patient care, research, teaching, and service to the community by leading innovation across our system. Founded by Brigham and Women's Hospital and Massachusetts General Hospital, Partners HealthCare supports a complete continuum of care including community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities. Several of our hospitals are teaching affiliates of Harvard Medical School, and our system is a national leader in biomedical research.

We're focused on a people-first culture for our system's patients and our professional family. That's why we provide our employees with more ways to achieve their potential. Partners HealthCare is committed to aligning our employees' personal aspirations with projects that match their capabilities and creating a culture that empowers our managers to become trusted mentors. We support each member of our team to own their personal development-and we recognize success at every step.

Our employees use the Partners HealthCare values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration.

General Overview

Under the direction of the Ambulatory Safety Net (ASN) Nurse Manager, the ASN Patient Navigator will help patients overcome barriers to getting necessary follow up care. Missed and delayed diagnoses are significant consequences of diagnostic error in ambulatory care, sometimes caused by a lack of test result follow up. The Ambulatory Safety Net team helps to design and implement closed loop communication systems to prevent missed or delayed diagnoses of abnormal test result follow up. The current focus of the Ambulatory Safety Net program is on preventing colorectal and lung cancers, with plans to quickly expand tracked conditions. To help patients receive appropriate follow up care and avoid missed or delayed diagnoses, the Navigator will review the electronic health record (Epic), manage follow up tracking lists, collaborate with clinical departments across the MGB enterprise, and connect directly with patients and their clinical team. This position requires strong communications skills, problem solving, teamwork, and dedication to improving the lives of our patients.

Principal Duties and Responsibilities

• The Navigator will use a standardized workflow consisting of the following high-level steps to ensure patients in the Ambulatory Safety Net received appropriate follow up care:
• Utilize and manage a follow up care tracking list to identify patients overdue for follow up care
  
• Perform chart review in the EHR (Epic) to determine if follow-up care is needed
  
• Direct clinical questions to RN Nurse Manager
  
• Collaborate with specialty departments and the patient's care team to identify barriers and find potential resolutions to issues that are preventing appropriate follow up care
  
• Contact the patient through EHR messaging, phone calls, or mail, as needed, to provide care coordination, ensuring culturally sensitive communication
  
• Share tools/resources with the patient to ensure they are prepared for the follow up care needed
  
• Ensures that all relevant health care information is documented completely, and that relevant information is communicated to patient's care team when appropriate and in accordance with HIPAA guidelines.
  

• Coordinate health care for patients with chronic conditions and those due for diagnostic testing or follow-up imaging studies with respect to primary care and specialty practice requirements.
  
• Assist with patient outreach and scheduling attempts required by specialty group practices for patients with non-MGB PCPs.
  
• Coordinate with operational contacts at each entity as needed, to facilitate with scheduling and communication to patients
  
• Contributes to quality improvement and process design of patient navigation models in collaboration with RN Manager, Sr. Program Manager, and other teams in PHM and departments across MGB
  
• Liaises with relevant specialty groups such as Gastroenterology, Radiology, Urology, OBGYN and others as needed
  

• Utilizes IT tools (e.g. population health registries) to manage assigned population specific activities
  
• Works collaboratively with practice care teams to identify interventions/resources needed to support patient participation in appropriate tests or follow-up imaging studies
  
• Learns and becomes proficient in available electronic health information systems such as Epic and follow up tracking lists/registries
  
• Perform other duties and tasks as assigned.
  

Qualifications
Qualifications

• Bachelor's degree preferred, especially in health sciences, but not required.
  
• Strong computer skills required; working knowledge or familiarity with electronic health records or other health care related IT systems desirable.
  
• Prior healthcare experience and understanding of medical terminology strongly preferred
  
• Customer service experience within healthcare services, community and/or multicultural settings.
  

• Experience as a community health care worker or patient advocate preferred.
  

Skills/Abilities/Competencies

• Commitment to patient advocacy, patient safety, and care coordination with the ability to champion issues and identify the appropriate resources
  
• Relationship Building: Ability to develop effective relationships with a broad array of people from diverse backgrounds and various levels of the management hierarchy, including influencing skills to engage clinicians and other leaders.
  
• Demonstrated ability to effectively work with clinical staff a plus.
  
• Strong interpersonal communication skills
  

• Ability to interview patients using interactive techniques (e.g. motivational interviewing, active listening) to identify potential barriers to care
  
• Strong ability to recognize problems, think creatively and devise solutions
  
• Ability to organize and prioritize workload; effective time and task management skills in achieving program initiatives and priorities
  
• Work as a member of a collaborative, multidisciplinary team
  
• Be flexible, sensitive and ready to adapt to changes in patients' needs and or their willingness to participate in their health care, including undergoing the screening process
  

• Highly organized, proactive and attentive to details
  
• Spanish fluency a plus
  
• Proficient in Microsoft Applications including MS Office

EEO Statement
Partners HealthCare is an Equal Opportunity Employer & by embracing diverse skills, perspectives and ideas, we choose to lead. 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.

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