Patient Health Coordinator/LPN

HarmonyCares•Virginia Beach, VA

About The Position

The Patient Health Coordinator (PHC) supports Medical Group patients through care coordination and ongoing monitoring of their progress. This detail-oriented, analytical problem solver collaborates with the Integrated Care Team to implement patient-centered care plans and guide patients and families through their healthcare journey. The role includes managing transitions of care, connecting patients with community services and resources, and addressing quality-of-care gaps. The PHC works with providers, support staff, patients, families, caregivers, facilities, external providers, third-party entities, and community resources.

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 role 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.
Act as a liaison between providers and patients by coordinating in-market activities, relaying messages, processing referrals and faxes, and handling prior authorizations.
Monitor and evaluate the effectiveness of interventions and treatments, and collaborate with the Integrated Care Team to determine whether care-plan adjustments are needed.
Advocate for patients during High-Risk Huddles by sharing assessments and recommendations with the Integrated Care Team.
Contact patients discharged from hospitals or emergency rooms to collect information and close care gaps.
Identify, document, and resolve problems, goals, and interventions in care plans, adding problem, goal, and intervention (PGI) information as needed.
Communicate clinical information and instructions to patients, caregivers, facilities, and others on behalf of providers, as directed.
Participate as an active member of the collaborative care team, including in High-Risk Huddles, to support quality and patient-experience outcomes.
Identify and ensure closure of social determinants of health barriers.
Proactively monitor patients through outreach and checkpoints established in their care plans.
Promptly document phone calls and patient interactions in the EHR according to company guidelines and applicable laws and regulations.
Communicate clearly and compassionately with patients, family members, the care team, and external entities, representing the company professionally and courteously.
Identify, acknowledge, escalate, or address patient complaints, grievances, and concerns in a timely and effective manner.
Comply with state and federal laws, including HIPAA.