Regional Complex Care Coordinator

The Opportunity

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

• 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.

• 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.

• Bachelor's Degree in a health-related field, public health, or human services.
• Related experience in lieu of degree may be reviewed and considered.
• 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.
• Bilingual Spanish / English highly preferred for many sites, including Boston and Jaimica Plain sites.

• 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 and time management skills.
• Exceptional ability to work autonomously while supporting a multidisciplinary team.

• Great benefits and retirement plans
• Experience navigating a large healthcare system as a liaison to patients
• Valuable connections in your assigned region
• Experience in a fast paced, mission driven organization where the patient comes first
• Cross collaboration with MGB colleagues, RNs and patient care team

Coordinators will be assigned multiple sites within one region, based on business needs, geographic preference and current home address.

• M-F Eastern Business Hours
• Reliable transportation required
• Onsite weekly travel includes Somerville / Community practices within region you are assigned;
  North, South, East or West
• Up to 5 days onsite weekly at various locations, community practices, must be flexible within assigned region and patient needs, typically 1 day remote work per week
• Monthly meetings onsite in Somerville, scheduled with notice
• Must be open to Somerville and assigned Primary Care sites, local to assigned region for weekly onsite commuting needs
• Remote work requires stable, secure, quiet, HIPAA compliant working station

Bilingual Spanish / English highly preferred for Jamaica Plain, MA

• Marblehead, MA and Swampscott, MA
• Lynn, MA
• Peabody, MA
• Beverly, MA
• Danvers, MA
• Newburyport, MA/ Peabody, MA
• Haverhill/Lawrence, MA
• Salem, MA
• Saugus, MA
• Practices can also include Cape Code area - Woods Hole and the Islands (Martha's Vineyard Oak Bluffs, MA and Nantucket Cottage Hospital)

New Hire will be aligned to region and practices within based on business need and proximity.

Mass General Brigham…