Patient Health Coordinator (LPN or Community Health Worker)

Patient Health Coordinator (LPN or Community Health Worker) position at HarmonyCares, a national value-based provider of in-home primary care services for patients with complex healthcare needs. The role is based in Reading, Pennsylvania, and operates within an integrated, team-based model supporting home-based primary care across multiple states. The schedule follows daytime hours with no weekends or holidays and manageable patient rosters.

Responsibilities

• Assist with care coordination for a caseload of paneled patients
• Collaborate with cross-functional teams to implement patient-centered care plans
• Coordinate in-market activities such as relaying messages, processing referrals and faxes, and handling prior authorizations
• Monitor and evaluate effectiveness of interventions and treatments, adjusting care plans as needed in collaboration with providers or Nurse Care Managers
• Advocate for patients during High-Risk Huddles by providing assessments and recommendations
• Conduct outreach to patients discharged from hospitals or emergency rooms to close care gaps
• Identify, document, and resolve problems, goals, and interventions in care plans using PGI documentation
• Communicate clinical information and instructions to patients, caregivers, and facilities as directed by providers
• Participate as an active member in High-Risk Huddles to support quality and patient experience outcomes
• Identify and address Social Determinant of Health barriers
• Perform proactive outreach and checkpoints based on established care plans
• Document all phone calls and patient interactions in the EHR according to clinical documentation guidelines and regulatory requirements
• Escalate and address patient complaints, grievances, and concerns in a timely manner
• Adhere to all state and federal laws including HIPAA

Requirements

• High school diploma or GED
• 2+ years of care coordination or healthcare experience
• Familiarity with Medicare, Medicare Advantage, and Medicaid insurances and programs
• Knowledge of basic medical terminology
• 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
• Active LPN/LVN license in the state where patients are located, Foreign Nursing Grad, Foreign Medical Grad, or Community Health Worker certification (preferred)
• Experience in Athena (EHR) (preferred)

Benefits

• Health, dental, vision, disability, and life insurance
• 401K 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