Patient Health Coordinator ( LPN)

About the role

HarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Our mission is to bring personalized, quality-based healthcare to the home of patients who have difficulty accessing care. We operate home-based primary care practices in 14 states, employing over 200 primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model.

The Patient Health Coordinator (PHC) plays a vital role in supporting Medical Group patients by assisting with care coordination and actively monitoring progress. This role requires a highly analytical, detail-oriented problem solver who collaborates with the team to implement a patient-centered care plan and guide patients and their families throughout their healthcare journey.

Responsibilities

• Assist with care coordination efforts and needs for a caseload of paneled patients.
• Collaborate with cross-functional teams to solve problems and achieve objectives.
• Act as the liaison between the provider and patient by coordinating in-market activities, including relaying messages, processing referrals and faxes, and handling prior authorizations.
• Monitor and evaluate the effectiveness of interventions and treatments; critically assess patient responses and adjust care plans as necessary in collaboration with the integrated care team.
• Advocate for patients’ well-being, ensuring they receive the care and support they need, including providing assessments and recommendations during High-Risk Huddles.
• Outreach to patients discharged from the hospital and/or emergency room to understand, collect information, and close care gaps.
• Identify, document, and resolve problems, goals, and interventions in care plans, updating them as needed.
• Communicate clinical information and instructions to patients, caregivers, facilities, and external providers on behalf of providers, as directed.
• Work as part of a collaborative care team to achieve optimal quality and patient experience outcomes, including active participation in High-Risk Huddles.
• Identify and ensure closure of Social Determinant of Health Barriers.
• Proactively monitor patients' care through outreach efforts and regularly established checkpoints based on care plans.
• Document all phone calls and patient interactions in the EHR promptly, adhering to standard clinical documentation guidelines.
• Maintain clear and compassionate communication with patients, family members, care team, and external entities, representing the company professionally.
• Appropriately identify, acknowledge, escalate, and/or address patient complaints, grievances, and concerns in a timely manner.
• Adhere to all state and federal laws, including HIPAA.

In this role, you may work with:

• Providers
• Support staff
• Care Team
• Patients
• Patient Families
• Caregivers
• Facilities
• 3rd party entities
• External Providers
• Community Resources

Requirements

• High school diploma/GED.
• 2+ years of care coordination or healthcare experience.
• Familiarity with Medicare, Medicare Advantage, and Medicaid insurances and programs.
• Well-organized, detail-oriented, and able to multi-task in a demanding and constantly changing environment.
• Strong interpersonal communication skills, including active listening.
• Demonstrated flexibility in addressing changing community needs and program environments.
• Ability to think critically and make sound judgments.
• Strong time management skills.
• Strong commitment to patient advocacy.
• Self-directed with excellent problem-solving skills.
• Knowledge of basic medical terminology.
• Ability to work independently and as part of a team.
• Proficiency with EMR software/application, call center technology, and Microsoft Office Suite.
• Experience in a community work or healthcare environment.
• Knowledge of basic principles, practices, and techniques in primary healthcare.

Preferred Qualifications

• Active LPN/LVN license in the state where patients are located, Foreign Nursing Grad, Foreign Medical Grad, or Community Health Worker certification.
• Experience in Athena (EHR).
• 2+ years of experience delivering exceptional customer service.
• 2+ years of experience in a position that involved critical thinking.

Benefits

• Health, Dental, Vision, Disability, and Life Insurance.
• 401K Retirement Plan (with company match).
• Tuition, Professional License, and Certification Reimbursement.
• Paid Time Off, Holidays, and Volunteer Time.
• Paid Orientation and Training.
• Daytime hours (no holidays/weekends).
• Manageable rosters and visits per day compared to a traditional practice environment.
• Great Place to Work Certified.

More details about the benefits we offer can be found at https://careers.harmonycares.com/benefits.

Pay

Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.