Patient Health Coordinator

HarmonyCares • Grand Rapids, MI

3d

About The Position

The Patient Health Coordinator (PHC) supports Medical Group patients through care coordination and ongoing monitoring of their progress. This analytical, detail-oriented problem solver works with the Integrated Care Team to implement patient-centered care plans and guide patients and families through their healthcare journey. The role supports care coordination activities such as managing transitions of care, facilitating access to community services and resources, and addressing quality care gaps.

The PHC coordinates activities for a caseload of paneled patients, serves as a liaison between providers and patients, monitors responses to interventions, advocates for patients during High-Risk Huddles, and conducts outreach after hospital or emergency-room discharge. The role documents patient interactions in the EHR, communicates instructions on behalf of providers as directed, helps resolve social determinants of health barriers, and addresses patient concerns while complying with HIPAA and applicable state and federal laws.

The position works with providers, support staff, care teams, patients, families, caregivers, facilities, third-party entities, external providers, 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.
• Well-organized and detail-oriented, with the ability to multitask in a demanding and 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-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 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, foreign medical graduate, or Community Health Worker certification.
• Experience using 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 and efforts 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, including relaying messages, processing referrals and faxes, and handling prior authorizations.
• Monitor and evaluate the effectiveness of interventions and treatments, assess patient responses, and collaborate with the integrated care team to determine whether care plan adjustments are needed.
• 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, adding problem, goal, and intervention details as needed.
• Communicate clinical information and instructions to patients, caregivers, and facilities on behalf of providers, as directed.
• Participate in collaborative care team efforts to achieve quality and patient experience outcomes, including active participation in High-Risk Huddles.
• Identify and ensure closure of social determinants of health barriers.
• Proactively monitor patients through outreach and checkpoints established in 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, families, care teams, and external entities, representing the company professionally and courteously.
• 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: Mid Level
• Education Level: High school or GED