Patient Liaison - Dorchester (Vietnamese Speaker Preferred)

About the role

Our older adult patients living in communities that we serve are faced with a variety of social challenges, called “Social Determinants of Health” (SDOH). Internally called “Gather Guide Partner,” this individual will work closely with our patients to identify their needs, research solutions that address various barriers, and ultimately enable them to gain access to critical resources. These challenges include food insecurity, social isolation and loneliness, lack of transportation, and more.

The Gather Guide Partner (GGP) will get to know our patients and their unique situations, becoming their trusted and consistent point-of-contact. The GGP will collaborate with primary care providers, Medical Technician Partners (EMTs), and clinic administrators as part of the care-team model. This partnership allows us to care for the “whole” patient, rather than only focusing on their physical health. The GGP plays a significant role in providing the best care and support with a deep sense of commitment and compassion, ultimately achieving our vision of creating equity in healthcare.

Responsibilities

• Conduct face-to-face screenings with new patients to identify their individual social needs and document notes.
• Ensure social re-screenings are completed for existing patients at least once yearly (in clinic or over the phone).
• Collaborate with the patient and care team to develop personalized social care plans for each patient.
• Follow up with patients considered to be high ER/hospital utilizers to check in on health status after an admission.
• Check in regularly with patients struggling with both health and severe SDOH concerns.
• Facilitate Durable Medical Equipment (DME) coordination.
• Answer inbound clinic calls to provide high-level and customized service.
• Complete administrative tasks related to SDOH or DME needs.
• Research various community resources relevant to the needs of our patients.
• Continuously expand our network of resources to address gaps such as transportation, food, activities, social connections, and other SDOH.
• Facilitate patient group activities in our common social events space.
• Identify and facilitate creative methods for providing individualized support for patients in need.

Requirements

• Minimum of one year of experience working in medical settings, community-based organizations, hospitality, or other related service industries.
• Experience working one-on-one with patients and/or customers.
• Experience in roles requiring frequent communication on the phone and in-person.
• Proficiency with basic office tools such as email and Outlook calendar.
• Strong verbal, written, and reading comprehension skills in English.
• Ability to work regular office hours Monday through Friday.
• Ability to work for any employer in the United States.

Preferred Qualifications

• Experience working with seniors or individuals with complex social needs.
• Experience working in a primary care office.
• Associates or bachelor’s degree.
• Experience as a birth or end-of-life doula.
• Bilingual in English and Vietnamese.

Traits for Success

• Compassionate – treats people with kindness.
• Patient – not easily frustrated or flustered.
• Nonjudgmental – gives others the benefit of the doubt.
• Understanding – recognizes that everyone has unique struggles.
• Helpful – finds fulfillment in adding value to others’ lives.
• Friendly – people enjoy their company.
• Outgoing – enjoys mingling with others and getting to know new people.
• Relatable – naturally makes human connections with warmth, humor, and demeanor.
• Positive – sees the glass as half full.
• Flexible – can easily pivot based on business needs.
• Dedicated – committed to serving others.
• Organized – manages time effectively and operates efficiently.
• Reliable – takes responsibilities seriously and always shows up on time.

Schedule

Monday – Friday during standard business hours.

About the Company

Gather Health delivers Social Primary Care to older adults. Through our unique and differentiated care model and proprietary technology, Gather Health’s solution drives substantial care outcomes by addressing the whole-person needs of our target demographic: older, dual-eligible adults, the fastest-growing government segment.

To address the needs of these clinically and socially complex patients, Gather Health’s Social Primary Care solution is comprehensive and holistic, encompassing care and community within the four walls of Gather Health Centers and in the homes of its patients. Gather’s model achieves superior care by individualizing care and is reinforced by a three-prong approach: a unique care model quarterbacked by PCPs and supported by multidisciplinary care teams, tailored Social Care Plans led by Gather Guides and facilitated by deeply rooted community partners, and a proprietary “Tech Enabled Home Model.”

Founded in 2022 and born out of the Healthcare Foundry Portfolio, Gather Health is addressing a $1 trillion market in primary care for older adults. Today, Gather Health operates in Massachusetts and works with a multitude of payer partners on aligning value-based care economics to deliver integrated care. Gather’s leadership team has a track record of building and scaling innovative primary care platforms focused on vulnerable populations, including VillageMD and Commonwealth Care Alliance. Gather has raised $30M backed by Maverick Ventures, Khosla, and HC9 Ventures.

Benefits

• Comprehensive medical, dental, and vision with day-one eligibility.
• Company-paid life, short-term, and long-term disability insurance.
• 401(k) with company match and immediate vesting.
• Generous PTO that increases with tenure and 11 paid company holidays.
• Employee Assistance Program (EAP) and supplemental benefit options.