Patient Health Coordinator/LPN

HarmonyCares • Virginia Beach, VA

4d

About The Position

HarmonyCares is a national value-based provider of in-home primary care for people with complex healthcare needs. The Patient Health Coordinator (PHC) supports Medical Group patients through care coordination and active monitoring of their progress. The role calls for an analytical, detail-oriented problem solver who collaborates with the team to implement patient-centered care plans and guide patients and families throughout their healthcare journey.

As a member of the Integrated Care Team, the PHC helps manage transitions of care, connect patients with community services and resources, and address quality care gaps. The position coordinates between providers and patients, monitors how patients respond to interventions, advocates for patient well-being, and helps ensure appropriate follow-up and documentation.

Requirements

• High school diploma or GED.
• At least 2 years of care coordination or healthcare experience.
• Familiarity with Medicare, Medicare Advantage, and Medicaid insurance and programs.
• Strong organization, attention to detail, and ability to multitask in a demanding, changing environment.
• Strong interpersonal communication skills, including active listening.
• Flexibility in responding to changing community needs and program environments.
• Ability to think critically and make sound judgments.
• Strong time management skills.
• Strong commitment to patient advocacy.
• Self-direction and excellent problem-solving skills.
• Knowledge of basic medical terminology.
• Ability to work independently and as part of a team.
• Proficiency with EMR software or applications, 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.

Nice To Haves

• Active LPN/LVN license in the state where patients are located, foreign nursing graduate or foreign medical graduate background, or Community Health Worker certification.
• Experience with Athena EHR.
• At least 2 years of experience delivering exceptional customer service.
• At least 2 years of experience in a position involving critical thinking.

Responsibilities

• Assist with care coordination needs for a caseload of paneled patients.
• Collaborate with cross-functional teams to solve problems and achieve objectives.
• Coordinate in-market activities as a liaison between providers and patients, including relaying messages, processing referrals and faxes, and handling prior authorizations.
• Monitor and evaluate the effectiveness of interventions and treatments, and work with the integrated care team to determine whether care plans need adjustment.
• Advocate for patients’ well-being and present assessments and recommendations to the integrated care team during High-Risk Huddles.
• Contact patients discharged from hospitals or emergency rooms to gather information and close care gaps.
• Identify, document, and resolve problems, goals, and interventions in care plans; update plans with problem, goal, and intervention details as needed.
• Communicate clinical information and instructions to patients, caregivers, facilities, and others on behalf of providers, as directed.
• Participate actively in High-Risk Huddles and collaborate with the care team to achieve quality and patient experience outcomes.
• Identify and help close social determinants of health barriers.
• Proactively monitor patients through outreach and checkpoints established in care plans.
• Document phone calls and patient interactions promptly in the EHR, following company guidelines and applicable laws and regulations.
• Communicate compassionately and professionally with patients, families, care team members, and external entities.
• Identify, acknowledge, escalate, and/or address patient complaints, grievances, and concerns in a timely and effective manner.
• Comply with state and federal laws, including HIPAA.

Benefits

• Health, dental, vision, disability, and life insurance.
• 401(k) retirement plan with company match.
• Tuition, professional license, and certification reimbursement.
• Paid time off, holidays, and volunteer time.
• Paid orientation and training.
• Daytime hours with no holidays or weekends.
• Manageable rosters and visits per day compared with a traditional practice environment.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED