Patient Health Coordinator

RiseMe; Richmond (VA); On-site; USD 42,000 - 62,000; Full time

Job summary

HarmonyCares in Richmond, VA is seeking a Patient Health Coordinator to support Medical Group patients by coordinating care, monitoring progress, and guiding families through the healthcare journey within the Integrated Care Team.

You will manage transitions of care, coordinate referrals, document calls in the EHR, and collaborate with providers, care managers, and external partners to close care gaps while upholding HIPAA and patient advocacy.

Qualifications

• 2+ years of care coordination or healthcare experience.
• Familiarity with Medicare, Medicare Advantage and Medicaid programs.
• Must be organized, detail-oriented and able to multi-task in a dynamic environment.
• Strong interpersonal communication and active listening skills.
• Ability to think critically and adapt to changing needs.
• Proficiency with EMR software, call center tech and Microsoft Office.
• Experience in community healthcare settings and basic medical terminology.
• Ability to work both independently and as part of a team.

Responsibilities

• Assist with care coordination and caseload management.
• Collaborate with cross-functional teams to meet objectives.
• Coordinate referrals, faxes, and prior authorizations between providers and patients.
• Monitor interventions and adjust care plans as needed.
• Advocate for patient well-being and participate in High-Risk Huddles.
• Outreach to discharged patients to close care gaps.
• Document all patient interactions in the EHR promptly.
• Communicate clinical information to patients and caregivers as directed.
• Identify and help resolve social determinants of health barriers.
• Ensure HIPAA compliance and professional, respectful interactions.

Skills

Care coordination experience

Healthcare experience

Medicare/Medicaid knowledge

Organizational skills

Interpersonal communication

Flexibility

Critical thinking

Time management

Patient advocacy

Problem solving

Medical terminology knowledge

Teamwork

Education

High school diploma/GED

Tools

EMR software

Call center technology

Microsoft Office Suite

Athena (EHR)

Job description

Overview

HarmonyCares is a leading national value-based provider of in‑home primary care services for people with complex healthcare needs. Headquartered out of Troy, Michigan, HarmonyCares operates home‑based primary care practices in 14 states. HarmonyCares employs more than 200+ primary care providers to deliver patient‑centered care under an integrated, team‑based, physician‑driven model.Our Mission– To bring personalized, quality‑based healthcare to the home of patients who have difficult accessing care.Our Shared Vision– Every patient deserves access to quality healthcare.Our Values– The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.Why You Should Want to Work with Us- Health, Dental, Vision, Disability & Life Insurance, and much more- 401K Retirement Plan (with company match)- Tuition, Professional License and Certification Reimbursement- Paid Time Off, Holidays and Volunteer Time- Paid Orientation and Training- Day Time Hours (no holidays/weekends)- Manageable rosters and visits per day compared to a traditional practice environment- Established in 11 states- Largest home‑based primary care practice in the US for over 28 years, making a huge impact in healthcare today!More details about the benefits we offer can be found at https://careers.harmonycares.com/benefits.

Responsibilities

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.

Essential Duties and 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, escalated and/or address patient complaints, grievances, and concerns in a timely and effective manner
• Adhere to all state and federal laws, including HIPAA

In this role you may work with. . .

• Providers
• Support staff
• Care Team
• Patients
• Patient Families
• Caregivers
• Facilities
• 3rd party entities
• External Providers
• Community Resources

Qualifications

Required Knowledge, Skills, and Experience

• 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

Preferred Knowledge, Skills and Experience

• 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

Pay Transparency

Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job‑related considerations.