Care Concierge

Lange Recruiting•Richmond, VA

4d•Hybrid

About The Position

At Home Harmony's Care Concierge Team is made up of experienced RN, LPN and MA staff who are passionate about case management and clinical support for our home based medical and pharmacy practice for aging adults. The Care Concierge / RN works with their medical provider, the patients and their family members/caregivers to provide coordinated case management and medical support from a REMOTE environment - a hybrid workplace of company HQ, home and possible senior living community. Duties and Responsibilities of the Care Concierge / RN: Clinical Support (Remote via phone) Triaging patients over the phone Facilitating patient scheduling in EMR Recording patient information and data in the EMR Manage EMR inbox needs Return patient calls and provide consistent communication between medical provider, patient, other department leads and external partners. Order, track and post results for provider review of diagnostic testing Order DME Monitor remote patient tools such as blood pressure, pulse ox, etc. and contact patients based on clinical criteria for abnormal readings Other duties as requested Case Management (Remote via phone) This involves talking on the phone, utilization of computer programs such as EMR and additional systems, and, periodically, time at senior living communities or riding in vehicle to the place of service. Create comprehensive and personalized care plans for enrolled patients Assists patients in transitions of care including hospital discharges, rehab admissions/discharges, scheduling follow-up appointments, assisting with home health orders and plan of cares, and other patient-specific needs May be required to complete in-person assessments in order to set up RPM devices Work with the AHH team of providers and other support staff to provide ongoing chronic care management to full panel of patients Provide education regarding disease management risk reduction, strategies and tactics. Complete concise, clear, timely documentation in the EMR and supporting software to meet documentation requirements. Promote At Home Harmony's Coordinated Model of Care of Medical and Pharmacy

Requirements

5 years' experience in at least one of the following settings: case management, disease management, home health care, hospital or outpatient office setting
Experience in Geriatrics, Family Practice, Internal Medicine, Cardiac or Pulmonary with a passion for working with the Geriatric population
Current unrestricted VA license/certification, required
Current BLS, required
2 years electronic medical record (EMR) experience Athena EMR, preferred
Knowledge of chronic care monitoring/management, preferred
Strong technology skills use of various systems
Strong, professional oral and written communication skills
Outgoing, adaptable and friendly personality
Motivated and flexible to changing needs of the program, team and work environment, with ability to self-direct in certain prioritization of tasks
Ability to efficiently work remotely and continue to meet productivity metrics
Knowledge of physician office practice operations, preferred
Valid drivers license with clean driving record
Ability to lift and carry equipment up to 50 pounds
Ability to walk up and down several flights of stairs easily

Nice To Haves

2 years electronic medical record (EMR) experience Athena EMR, preferred
Knowledge of chronic care monitoring/management, preferred
Knowledge of physician office practice operations, preferred

Responsibilities

Triaging patients over the phone
Facilitating patient scheduling in EMR
Recording patient information and data in the EMR
Manage EMR inbox needs
Return patient calls and provide consistent communication between medical provider, patient, other department leads and external partners.
Order, track and post results for provider review of diagnostic testing
Order DME
Monitor remote patient tools such as blood pressure, pulse ox, etc. and contact patients based on clinical criteria for abnormal readings
Create comprehensive and personalized care plans for enrolled patients
Assists patients in transitions of care including hospital discharges, rehab admissions/discharges, scheduling follow-up appointments, assisting with home health orders and plan of cares, and other patient-specific needs
May be required to complete in-person assessments in order to set up RPM devices
Work with the AHH team of providers and other support staff to provide ongoing chronic care management to full panel of patients
Provide education regarding disease management risk reduction, strategies and tactics.
Complete concise, clear, timely documentation in the EMR and supporting software to meet documentation requirements.
Promote At Home Harmony's Coordinated Model of Care of Medical and Pharmacy