Patient Navigator

This position is integral to the operation of clinical services delivered under the CMS GUIDE model. The care navigator will serve as a primary point of contact for person with dementia and their caregivers and coordinate a range of services, described in detail below. They will also have responsibility for aggregating data collected and coordinating communication with CMS.

Responsibilities related to implementing the GUIDE Model:

* Coordinating intakes and approval for beneficiaries to participate in GUIDE

* Conduct Home Visit Assessments: safety of home, ADL assessment, environmental factors

* Participate in developing person-centered care plan for GUIDE beneficiary and caregiver, where applicable

* Serving as primary point of contact for the GUIDE Beneficiary and their Caregiver.

* Managing the person-centered care plan as needed, identifying unmet needs and coordinating clinical and community-based services and supports, monitor medication management and adherence, and provide caregiver education and support.

* Serving as liaison with the Care Team's clinical team members for any medical or other issues that present with complexity, and coordinating care with PCPs and other providers.

* Additional care coordination responsibilities as required by the GUIDE Care Team.

* Providing additional information and supports to help the GUIDE Beneficiary as indicated, including maintaining a directory of resources in the service region for McLean.

* Coordinating caregiver support as required by the GUIDE Model agreement, including providing resources and one-on-one calls to facilitate care as needed. .

* Coordinating peer-to-peer support services as indicated, in consultation with the care team.

Responsibilities related to Management of the Project:

* Coordinate preparation and communication of progress reporting and deliverables to sponsor

* Develop, communicate, and execute project timelines, milestones, KPIs.

* Support key external-facing activities and initiatives

* Develop and operationalize a QA/QC plan for cleaning and maintenance of data

* Oversee database management as required

* Perform data quality audits as required

* Present and participate in regular meetings with members of the operational and clinical teams

* Oversee day-to-day operations of project

* Contribute to development and revision of project policies, procedures, and toolkits

* Prepare manuscripts, abstracts, posters, and presentations

* Project administrative activities as required

* Supervise research assistants or administrative staff who will work on GUIDE models roles.

* Maintain regulatory oversight of all project-related and project adjacent initiatives (e.g. research projects embedded within GUIDE), including supporting IRB applications and preparing annual reports.

* Use/s the Mass General Brigham 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

* Other duties as assigned

* Bachelors degree is preferred

* A combination of education and experience may be substituted for requirements

* Experiece working with older adults and/or persons with dementia.

* Completing training required by CMS, to serve in the care navigator role.

* Possess strong interpersonal skills to effectively communicate with cross functional teams including staff at all levels of the organization

* Ability to successfully negotiate and collaborate with others of different skill sets, backgrounds an levels within and external to the organization

* Strong problem solving and negotiation skills

* Ability to effectively conduct meetings, both formal and informal

* Requires minimal direction from leadership and possesses the ability to learn quickly