Patient Health Coordinator ( LPN, Hybrid)

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 delivering 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 & faxes, and handling prior authorizations
• Monitor and evaluate the effectiveness of interventions and treatments; adjust care plans as necessary
• Advocate for patients’ well-being, ensuring they receive the care and support they need
• 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
• Communicate clinical information and instructions to patients, caregivers, and facilities on behalf of providers
• Work as part of a collaborative care team to achieve optimal quality and patient experience outcomes
• Identify and ensure closure of Social Determinant of Health Barriers
• Proactively monitor patients' care through outreach efforts and regularly established checkpoints
• Document all phone calls and patient interactions in the EHR promptly
• Maintain clear and compassionate communication with patients, family members, care team, and external entities
• Appropriately identify, acknowledge, escalate, and/or address patient complaints, grievances, and concerns
• Adhere to all state and federal laws, including HIPAA

Requirements

• High school diploma/GED
• 2+ years of care coordination or healthcare experience
• Familiarity with Medicare, Medicare Advantage, and Medicaid insurances and programs
• Strong interpersonal communication skills and active listening abilities
• Ability to think critically and make sound judgments
• Strong time management and organizational skills
• Self-directed with excellent problem-solving skills
• Knowledge of basic medical terminology
• Proficiency with EMR software, call center technology, and Microsoft Office Suite
• Experience in a community work or healthcare environment

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 involving critical thinking
• Bilingual (Spanish and English)

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

Pay

Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations. The pay range for this role is USD $31.01–$35.00 per hour.