Chronic Disease Patient Navigator

Mass General Brigham (Enterprise Services)
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
May 02, 2025
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 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 Education Bachelor's Degree Clinical Social Work required or Bachelor's Degree Healthcare Management required or Bachelor's Degree 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 language(s) nice to have 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 a team member in multicultural settings Strong oral and written communication skills Highly organized, proactive and attentive to details Commitment to accuracy and integrity of all data, reports, and communications Proficient in all Microsoft Applications, including MS Office and Excel Strong knowledge of healthcare resources, community services, and patient advocacy. Excellent communication and interpersonal skills. Ability to work collaboratively with diverse healthcare professionals. Strong organizational and time management skills. Familiarity with electronic health records and case management software. Mass General Brigham Incorporated 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. 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.