Chronic Care Coordinator

3 weeks ago


Somerville, Massachusetts, United States Mass General Brigham (Enterprise Services) Full time
Job Summary

We are seeking a skilled Chronic Care Assistant to join our Population Health Management team at Mass General Brigham. The successful candidate will provide operational support in clinical operations focused on chronic care management, coordinating care for patients with chronic conditions.

Key Responsibilities
  • Conduct initial intake and assessment for patients identified or referred by a primary care clinician.
  • Deliver patient and caregiver condition-specific care protocols as appropriate.
  • Provide education to patient/caregiver on disease-specific information.
  • Manage data entry into Mass General Brigham EPIC system or other patient database.
  • Schedule initial patient virtual visit.
  • Evaluate and track patient enrollment status in the program.
  • Establish and schedule standard cadence for follow-up with patient. Connect patient to appropriate resources.
  • Manage care coordination needs for patient being followed, including social-related health needs.
  • Work closely with programs' interdisciplinary teams in providing patient care.
  • Support administrative needs of central team as needed.
Requirements
  • Bachelor's degree with 2 years of healthcare experience (internships and fellowships are considered as experience).
  • A combination of education and experience in a healthcare or related setting may be substituted for requirements.
Work Environment

This is a full-time position with a standard 40-hour workweek. The role will primarily work at the MGB office in Assembly Row with an ability to flex to remote work or travel to MGB primary care practice locations and community settings as needed.



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