Patient Health Coordinator

HarmonyCares • Kalamazoo, MI

4d

About The Position

The Patient Health Coordinator (PHC) supports Medical Group patients by coordinating care and monitoring progress. As a member of the Integrated Care Team, the PHC helps implement patient-centered care plans and guides patients and families through their healthcare journey. The role includes managing transitions of care, connecting patients with community services and resources, and addressing quality care gaps. The PHC collaborates with providers, Nurse Care Managers, support staff, patients, families, 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.
• Strong organizational and detail-orientation skills, 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.
• Critical-thinking skills and sound judgment.
• 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 for a caseload of paneled patients.
• Collaborate with cross-functional teams to solve problems and achieve objectives.
• Serve 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 work with the integrated care team to determine whether care-plan adjustments are needed.
• Advocate for patients during High-Risk Huddles by providing assessments and recommendations to the integrated care team.
• 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 in the collaborative care team to support quality and patient experience outcomes, including taking part in High-Risk Huddles.
• Identify and help resolve social determinants of health barriers.
• Monitor patients' care through outreach and checkpoints established in care plans.
• Promptly document calls and patient interactions in the EHR according to company guidelines and applicable laws and regulations.
• Communicate compassionately and professionally with patients, families, the care team, and external parties.
• Identify, acknowledge, escalate, 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