BFT RN CARE COORDINATOR

Mass General Brigham (MGB) Community Health is committed to improving health outcomes for all. The Clinical-Community Programs team in the Office of the Chief Medical Officer develops and implements innovative, community-based models of care that improve access to preventive services, strengthen care coordination, and address the social and clinical factors that influence health outcomes. This portfolio includes the Community Health Improvement (CHI) Corps, the MGB Community Care Vans and other community-based clinical initiatives designed to improve health of the populations we serve.

The Care Coordinator RN is a key member of the Clinical Community Programs team and will work collaboratively with the Senior Medical Director of Clinical Community Programs, physicians, advanced practice providers, CHI Specialists, primary care teams, and community partners to coordinate care for patients across community-based programs. The role supports clinical operations, patient navigation, care coordination, referral management, quality improvement initiatives, and performance management that enhance access to care and improve health outcomes.

A primary responsibility of this position is supporting the Community Health Improvement (CHI) Corps and Community Care Vans, with a particular focus on initiatives related to hypertension (HTN) management, colorectal cancer (CRC) screening, and other preventive health priorities. The RN will also provide clinical care coordination and operational support across additional Clinical Community Programs as organizational needs evolve.

The RN Care Coordinator will assist with patient outreach, care coordination, referral management, follow-up activities, and interdisciplinary communication across multiple neighborhoods and clinical programs. This role requires a strong understanding of community health, culturally responsive communication, care coordination strategies, and the ability to work effectively across both clinical and community settings.

This position reports directly to the Senior Medical Director of Clinical Community Programs.

• Collaborate closely with CHI Specialists and Community Care Van teams to support care coordination across designated priority neighborhoods.
• Collaborate closely with the Senior Medical Director of Clinical Community Programs on clinical questions, case review, protocol development, and care coordination strategies.
• Serve as a clinical resource to Community Health Improvement (CHI) Specialists and other program staff by providing guidance on clinical workflows, patient navigation, and appropriate escalation of clinical concerns.
• Conduct remote patient outreach via phone and virtual platforms to support improved health outcomes, preventive care initiatives, and continuity of care.
• Coordinate follow-up care for patients identified through community outreach, screenings, and Clinical Community Program initiatives.
• Facilitate referrals and warm handoffs between patients, primary care providers, specialists, community-based organizations, and other internal and external resources.
• Provide culturally responsive patient education related to hypertension prevention and management, colorectal cancer screening, chronic disease management, preventive care, and wellness.
• Support clinical care coordination across Clinical Community Programs, including participation in new program implementation and workflow development as organizational priorities evolve.
• Review patient registries, identify care gaps, and assist with outreach strategies to improve quality metrics and patient outcomes.
• Support initiatives aimed at improving health outcomes across underserved communities through evidence-based, community-centered care coordination.
• Document patient interactions, care coordination activities, and interventions accurately within the electronic medical record and other designated systems.
• Support data tracking, documentation, reporting, and analysis related to patient outreach, clinical outcomes, and program performance.
• Participate in interdisciplinary meetings, case conferences, and quality improvement initiatives to optimize patient care and operational workflows.
• Support program performance management by monitoring key performance indicators, identifying opportunities for improvement, and collaborating with interdisciplinary team members to enhance program quality, operational efficiency, and patient outcomes.
• Support quality assurance activities by promoting adherence to program standards, clinical workflows, documentation requirements, evidence-based practices, and organizational policies while identifying opportunities for continuous quality improvement.
• Maintain patient confidentiality and comply with all organizational privacy, regulatory, and compliance standards.
• Stay current on best practices in care coordination, population health, and community-based nursing to support continuous program improvement.
• Perform other duties as assigned in support of the Clinical Community Programs portfolio.

Qualifications -

• Current Massachusetts Registered Nurse (RN) licensure required.
• Bachelor of Science in Nursing (BSN) preferred.
• Minimum of 3-5years of nursing, care coordination, population health, or community health experience preferred.
• Experience working in community-based settings strongly preferred.

• Experience supporting chronic disease management and preventive health initiatives preferred.

Skills

• Strong care coordination and patient engagement skills.
• Ability to communicate effectively with patients, providers, and community partners.
• Knowledge of chronic disease prevention and preventive health strategies preferred.
• Ability to work independently in a remote work environment while maintaining strong collaboration with interdisciplinary teams.
• Strong organizational skills and attention to detail.
• Ability to manage multiple priorities and adapt to changing program needs.
• Demonstrated commitment to health equity and culturally responsive care.
• Proficiency with electronic medical records and virtual communication platforms.
• Ability to maintain confidentiality and comply with all local, state, and federal privacy regulations.