Patient Health Coordinator

Overview

Harmony Cares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered out of Troy, Michigan, Harmony Cares operates home-based primary care practices in 14 states. Harmony Cares 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
• Great Place to Work Certified
• 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

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.

• 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…