Patient Care Coordinator

Who We Are:

Heal is revolutionizing the healthcare experience by putting patients first. We provide tech enabled in-home primary care services for seniors, consisting of house calls, telemedicine and remote patient monitoring (RPM). We currently operate in New York, New Jersey, North Carolina, South Carolina, Georgia, Louisiana, Illinois, and Washington, with future plans for national expansion.

Since being founded in 2014, Heal has delivered over 250,000 house calls. We are proud to mention our very wide range of notable investors, including: Paul Jacobs, Humana, Jeb Bush, Breyer Capital, IRA Capital, Trans-Pacific Technology Fund, Lionel Richie, and more.

The Role:

We are looking for a patient care coordinator to provide exceptional, professional and compassionate care coordination services to the patients of Heal's contracted medical group "Heal Doctors". In this role, you will be the main care coordination resource, working in conjunction with Heal's operations and technology teams, clinicians, health plan case managers and other key stakeholders. You will develop and successfully implement policies and protocols to identify, follow, and support patients in achieving the best health outcomes in key quality measures, such as medication adherence and diabetes management, to avoid hospital admissions and emergency room utilization. This also includes understanding social determinants of health and how they impact a patient's health status. The ideal candidate should be excited about being a part of our unique model of care while being driven to make a significant impact on patient outcomes.

Job Responsibilities:

• Provide outreach and coordination services such as: proactive outreach to identify social behavioral and medical needs; answering patient calls; facilitating subspecialty and imaging appointments, including transportation as needed; referrals and prior authorizations.
• Ability to assess and identify patient's social determinants of health, such as housing, transportation, and access to nutritious food, to gain insight into how they may impact closing patient care gaps; work to coordinate services as needed to mitigate barriers.
• Identification of high-risk patients, which includes the subpopulation of patients with multiple, chronic comorbidities, through varying methods such as collaboration with Heal Doctors clinical teams, patients' caregivers, family and patients' health plans.
• Collaborate with case managers at Heal Doctors' contracted health plans to ensure attributed members receive timely, hassle-free access to medically necessary care.
• Execute on routine and proactive follow up with patients discharged from the hospital or emergency department.
• Monitor patient care gaps and work 1:1 with Heal providers to schedule services needed to close open gaps that will improve Heal's STAR rating and assist patients in obtaining the best health outcomes.
• Provide motivational interviewing, literature, and resources as needed to support behavioral change.
• Maintain accurate and complete documentation of all care coordination services and ensure notes are entered into the EMR contemporaneously with services.
• Educate Heal's Patient Support and Provider Operations teams on internal policies and protocols and other best practices relating to coordinating patient care.
• Work cross functionally with Heal Doctors' clinical teams and Heal's technology team to design practices and processes that incorporate Heal technology and assist in proactive, medically appropriate follow-up with high-risk patients.

Requirements:

• Bachelor's or equivalent degree.
• Minimum of 1 year of professional experience in or close to case management.
• Exhibit a knowledge and understanding of HEDIS and STAR quality measures and ratings.
• Knowledge of community resources in applicable geographic areas.
• Ability to work in a fast-paced environment which includes multi-tasking, prioritizing, and process-building with ambiguity.
• Familiarity working with and analyzing patient and quality data (e.g. Excel).
• Can navigate a matrixed organization with complex operations well - e.g. multiple systems, multi-step processes, multiple internal and external stakeholders.