Health Navigator - Frontier and LIFT Clinics

Education
Bachelor's Degree Health Administration required and Bachelor's Degree Social Work required and Bachelor's Degree Related Field of Study required

Can this role accept experience in lieu of a degree?
No

Licenses and Credentials

Experience:
Experience in care coordination, case management, or patient advocacy 2-3 years required and Experience working with a broad patient population and understanding of community health resources 2-3 years preferred

Knowledge, Skills and Abilities:
- Strong interpersonal and communication skills to effectively engage with patients, families, and healthcare providers.
- Knowledge of healthcare systems, insurance processes, and community health resources.
- Ability to work independently and manage multiple patient cases simultaneously.
- Problem-solving skills to identify and address barriers to care.
- Empathy and cultural sensitivity when working with patients from various backgrounds.

Patient Coordination & Administrative Duties:

• Serve as the primary point of contact for patients in the LIFT and FRONTieR programs.

• Manage incoming referrals, contact new patients, explain program pathways, and coordinate scheduling.

• Maintain clinic calendars, appointment schedules, and provide timely appointment reminders.

• Attend in-person clinics (LIFT - Tuesday mornings; FRONTieR - Friday mornings) to assist with clinical operations.

• Perform patient assessments, including InBody Scans and Frailty Testing.

• Conduct follow-up calls after clinic visits to assess barriers to care, confirm treatment plans, and coordinate follow-up needs.

• Provide ongoing support, including 2-week post-appointment check-ins to address clinical, referral, or resource needs.

• Facilitate care coordination among transplant, post-transplant, and other relevant departments within MGH.

• Assist with patient admissions, discharge planning, and communication with inpatient and outpatient teams.

• Distribute program announcements, support patient group sessions, and troubleshoot patient access or scheduling concerns.

• Track and monitor clinical tests (e.g., PEth orders), and communicate relevant updates to the care team.

• Maintain accurate documentation in EPIC and update resource databases and clinic spreadsheets.

Health Coaching & Patient Empowerment:

• Provide individualized health coaching to support behavior change, lifestyle modification, and wellness promotion.

• Utilize evidence-based approaches such as Motivational Interviewing (MI) and SMART goal setting.

• Empower patients to develop problem-solving skills and take actionable steps toward their health goals.

• Facilitate Virtual Group Visits (VGVs) and engage in sensitive, health-related discussions with empathy and professionalism.

• Connect patients to internal and community resources, including wellness programs, behavioral health, recovery services, and transportation support.

Data Collection & Program Development:

• Collect and manage patient-reported outcome measures (PROMs) and survey data.

• Support clinical research activities, including data coding, IRB submissions, and study coordination.

• Contribute to ongoing quality improvement initiatives within LIFT and FRONTieR clinics.

• Collaborate with clinical teams to optimize program operations and enhance patient experience.