Patient Health Coordinator

HarmonyCares•Houston, TX

4d•Onsite

About The Position

The Patient Health Coordinator (PHC) plays a vital role in supporting Medical Group patients by assisting with care coordination and actively monitoring the progress. This role requires a highly analytical and detail-oriented, problem solver that will collaborate with the team to implement a patient-centered care plan 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 but not limited to managing Transitions of Care, facilitating access to community services and resources, and addressing quality care gaps as necessary.

Requirements

High school diploma/GED
2+ years of care coordination or healthcare experience
Familiarity with Medicare, Medicare Advantage and Medicaid insurances and programs
Must be well-organized, detail-oriented, and can multi-task in a demanding and constantly changing environment
Strong interpersonal communication skills and the ability to communicate easily with others, including demonstrating active listening skills.
Demonstrate flexibility in addressing changing community needs and program environment
Ability to think critically and make sound judgments
Strong time management skills
Strong 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/application, 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 Grad, Foreign Medical Grad, or Community Health Worker certification
Experience in Athena (EHR)
2+ year of experience delivering exceptional customer service
2+ years of experience in a position that involved critical thinking

Responsibilities

Assist with care coordination efforts and needs for caseload of paneled patients
Collaborate with cross-functional teams to solve problems and achieve objectives
Acting as the liaison between the provider and patient by coordinating in-market activities, including but not limited to relaying messages, processing referrals & faxes, and handling prior authorizations
Monitor and evaluate the effectiveness of interventions and treatments; thinking critically about how the patient is responding and whether adjustments to the care plan are necessary. The PHC works collaboratively with the integrated care team (provider or Nurse Care Manager) to problem-solve through medical concerns.
Advocate for patients’ well-being, ensuring they receive the care and support they need. The PHC would advocate to the integrated care team during High-Risk Huddle and give their assessment and recommendation.
Outreach to patients who are 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. The PHC will update the care plan by adding PGI (problem, goal, intervention) as needed.
Communicate clinical information and instructions to patients/caregivers, facilities, etc. on behalf of providers, as directed
Work as part of a collaborative care team to achieve optimal quality and patient experience outcomes, including being an active member 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 by utilizing standard clinical documentation guidelines as required by the company and local, state and federal rules and regulations
Maintain clear and compassionate communication with patients, family members, care team, and other external entities, representing the company in a professional and courteous manner in all interactions
Appropriately identify, acknowledge, escalate and/or address patient complaints, grievances, and concerns in a timely and effective manner
Adhere to all state and federal laws, including HIPAA