Patient Health Coordinator

HarmonyCares • Portage, MI

1d

About The Position

The Patient Health Coordinator (PHC) supports Medical Group patients through care coordination and active monitoring of their progress. As a member of the Integrated Care Team, the PHC collaborates with providers, Nurse Care Managers, and other team members to implement patient-centered care plans and guide patients and families through their healthcare journey. The role includes coordinating transitions of care, connecting patients with community services and resources, and addressing quality care gaps.

The PHC serves as a liaison between providers and patients, monitors how patients respond to interventions, and works with the care team to identify when care-plan adjustments may be needed. The coordinator advocates for patients, helps address social determinants of health, and documents interactions in the EHR in accordance with company guidelines and applicable laws and regulations. The position involves communication with patients, families, caregivers, facilities, 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, 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 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 consider necessary adjustments to care plans.
• 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 entries as needed.
• Communicate clinical information and instructions to patients, caregivers, and facilities on behalf of providers, as directed.
• Participate as an active member of the collaborative care team and High-Risk Huddles to support quality and patient experience outcomes.
• Identify and ensure closure of Social Determinant of Health barriers.
• Proactively monitor patients through outreach and checkpoints established in care plans.
• Promptly document phone calls and patient interactions in the EHR using required clinical documentation guidelines.
• Communicate clearly and compassionately with patients, family members, care teams, and external entities, representing the company professionally.
• 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.

What This Job Offers

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