Patient Health Coordinator (LPN)

HarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered in Troy, Michigan, we operate home-based primary care practices in 14 states and employ over 200 primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model.

About the role

The Patient Health Coordinator (PHC) plays a vital role in supporting Medical Group patients by assisting with care coordination and actively monitoring progress. This highly analytical and detail-oriented role collaborates with the team to implement patient-centered care plans and guide patients and their families throughout their healthcare journey. As a key member of the Integrated Care Team, the PHC contributes to essential care coordination efforts, including managing Transitions of Care, facilitating access to community services, and addressing quality care gaps.

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
• Work collaboratively with the integrated care team (provider or Nurse Care Manager) to problem-solve medical concerns
• Advocate for patients’ well-being, ensuring they receive necessary care and support; provide assessments and recommendations during High-Risk Huddles
• Outreach to patients discharged from the hospital and/or emergency room to collect information and close care gaps
• Identify, document, and resolve problems, goals, and interventions in care plans; update care plans by adding PGI (problem, goal, intervention) as needed
• Communicate clinical information and instructions to patients, caregivers, facilities, and others 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 using standard clinical documentation guidelines
• Maintain clear and compassionate communication with patients, family members, care team, and external entities in a professional manner
• 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 teams, patients, patient families, caregivers, facilities, third-party entities, external providers, and community resources.

Requirements

• High school diploma or GED
• 2+ years of care coordination or healthcare experience
• Familiarity with Medicare, Medicare Advantage, and Medicaid insurances and programs
• Strong organizational skills, detail-oriented, and ability to multi-task in a demanding, constantly changing environment
• Excellent interpersonal communication skills, including active listening
• Flexibility in addressing changing community needs and program environments
• Critical thinking and sound judgment abilities
• Strong time management skills
• 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, 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 with Athena (EHR)
• 2+ years of experience delivering exceptional customer service
• 2+ years of experience in a position requiring 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 or weekends)
• Manageable rosters and visits per day compared to a traditional practice environment

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.