HarmonyCares

Telehealth Nurse

• Conduct comprehensive in-home health risk assessments to identify all active and chronic disease conditions, as well as determine all physical, mental, and social needs present at the time of the visit
• Takes history, examines, determines diagnoses.
• Provides written documentation of patient visit, per NCQA standards
• Takes patient vital signs, as necessary.
• Places case management referrals and communicates with PCP as necessary.
• Communicates with patients, caregivers, agency nurses, other providers and vendors as necessary to assure proper diagnosis.
• Performs all clinical duties while observing OSHA Universal Precautions
• Maintains patient confidentiality
• Attends required meetings and in-services and participates in committees, as requested
• Participates in professional development activities and maintains professional licenses and affiliations

PRN Nurse Practitioner – Telehealth

Affiliate Manager

• Assist Harmony Cares Primary Care Physician, Nurse Practitioners and Clinical Teams in the delivery of primary health care and patient care management in a residential setting
• Supports mission, vision and core values which include but not limited to delivering compassionate support, attention and assistance to patients, families and members of the team
• Support Patient Care through Clinical Partnership with Nurse Practitioners, Physicians, and Care Management Teams
• Coordinates daily travel itinerary and transports clinicians to scheduled appointments
• Prepares patients for examination and treatment; May at times include preparing patients for minor procedures
• Secures patient consent forms, records patient care documentation accurately and in a timely manner
• Coordinates patient care as directed by Clinicians, company standards and policies
• Respects patient confidentiality at all times and treats patients with courtesy and respect
• Performs phlebotomy (venipuncture only), EKG or any other procedure as requested by Clinician
• Labels, stores and properly packages specimens for lab delivery
• Assists In identifying and closure of quality gaps
• Documentation and updating of patient care plans, as well as SDoH (Social Determinants of Health) and other assessments within the patient chart or electronic medical record
• Required to maintain compliance with CLIA (Clinical Laboratory Improvement Amendments), OSHA, and HIPPAA guidelines
• Prepares and maintains supplies and equipment for treatment (supply inventory, medical bag and car) (where applicable)
• Ensure company vehicle is clean and proper periodic maintenance schedule is followed (where applicable)
• Attends required meetings and in-services

Medical Assistant, Clinical Partner

• Conduct comprehensive in-home health risk assessments to identify all active and chronic disease conditions, as well as determine all physical, mental, and social needs present at the time of the visit
• Takes history, examines, determines diagnoses. Provides written documentation of patient visit, per NCQA standards
• Takes patient vital signs, as necessary. Places case management referrals and communicates with PCP as necessary.
• Communicates with patients, caregivers, agency nurses, other providers and vendors as necessary to assure proper diagnosis.
• Performs all clinical duties while observing OSHA Universal Precautions
• Maintains patient confidentiality
• Attends required meetings and in-services and participates in committees, as requested
• Participates in professional development activities and maintains professional licenses and affiliations

PRN Nurse Practitioner, Home Visits/Telehealth

Primary Care Physician

• Act as on-site supervising Physician for assigned APPs, and Physicians assigned to the POD (collaborating physician).
• Total number of collaborative Practice agreements should not exceed state regulations.
• Collaborative time will correlate to assigned APPs and Physicians
• Participate in at least 1 ride along with all collaborative APPs per quarter
• Provide a complex patient visit as needed for each APP under supervision
• Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.)
• Develop and participate in APP clinical development (Evidenced based care, professionalism, etc.)
• Lead and participate in high-risk huddles and ensure all patients discussed have a plan of care documented and includes all care management team members
• Build team-based culture and work collaboratively with clinical team members
• Conducts 10 chart audits per month or per state regulations, whichever is higher
• Act as resource for clinical team members for patient care questions/concerns and participate in difficult conversations with patients/family members as requested by team
• Routinely conduct panel reviews with APPs
• Sign DME, death certificates, and other orders as needed on behalf of APP (as regulated by state)
• Frequently review Quality metrics, pod level performance and identify areas for improvement leading to superior Quality (HEDIS) performance
• Frequently review clinician capacity and productivity performance. Partner with Site Medical Directors to develop countermeasures and support their implementation when provides are off track
• Work collaboratively with Regional Medical Director (RMD) to identify opportunities for care improvement
• Assist with service inquiry, resolution of patient complaints and requests for Pod as needed
• Assist pod providers to achieve higher EMR efficiency
• Participate in patient care to assigned panel and other patients as needed (High risk or complex patients, Physician face to face requirements, cognitive assessments, etc.)
• Participate and lead clinical education regarding accurate diagnosis, documentation and management of chronic conditions
• Assist with compliance and HR resolutions
• Responsible for discipline actions and performance reviews for direct reports
• Additional duties as assigned by the Regional Medical Director as related to clinical pod performance and outcomes.

Physician Leader – Primary Care

Business Development Rep

• The Community Liaison is responsible for inbound/outbound communication and business development.
• The role acts as the local market B2B, B2C, and D2C representative educating community partners and potential patients about the company, our mission and service offerings.
• This role will help facilitate patient transitions of care from area facilities and referral partners to HarmonyCares and will explain the benefits of enrollment to eligible patients and caregivers.
• Market analysis, along with competitive landscape, in which to differentiate HarmonyCares services to external referral partners
• Know and educate the community on our mission to provide high-quality personalized healthcare in the home for people that need it the most
• Meet or exceed agreed upon in person and virtual meeting goals with key decision makers
• Thoroughly understand eligibility and enrollment processes
• Provide education on and facilitate, as requested, benefit enrollment and processes
• Track performance in CRM demonstrating plan and adherence to budgeted targets for a given region
• Schedule face-to-face or phone discussions with patients and their caregivers (or other legal representatives) to provide guidance on patient eligibility for all programs
• For patients interested in being aligned or attributed to an accountable care organization (or other CMS alternative payment model) in which one of the Company’s practices are participating, inform them about the program; and, if they opt to voluntarily align, collect Voluntary Alignment Form from patients (or their legal representatives)
• Answer inbound calls from patients, families, and facility staff members regarding the Company’s business units operating in the relevant market
• Promptly, accurately, professionally triage all patient concerns related to care needs, scheduling and billing to the appropriate department
• Oversee and document outreach calls conducted, and meetings scheduled with external sources
• Adhere to all company policies and procedures and all applicable laws and requirements, including without limitation those related to marketing (including marketing plans), interacting with referral sources and patients, beneficiary notifications, and conducting patient outreach (i.e., calls and in person)
• Comply with HIPAA privacy and security guidelines and company policies, procedures and standards
• Maintain consistent communication with sales leaders and local business unit leadership and support staff
• Performs other additional duties as assigned

Community Liaison – Business Development

• The Medical Pod Leader will be the clinical leader responsible for the clinical performance of clinical pod team members – to include: Accurate diagnosis and documentation, quality, patient experience, affordability, patient safety, clinical team dynamics, and provider productivity.
• The pod leader will be tasked with developing and maintaining close working relationships with all clinical team members in the clinical pod.
• The pod leader will also function as the collaborating physician for associated pod advanced practice providers (APPs).
• This position will have a dyad partnership with the Market Manager and market office staff.
• Act as on-site supervising Physician for assigned APPs, and Physicians assigned to the POD (collaborating physician).
• Total number of collaborative Practice agreements should not exceed state regulations.
• Collaborative time will correlate to assigned APPs and Physicians
• Participate in at least 1 ride along with all collaborative APPs per quarter
• Provide a complex patient visit as needed for each APP under supervision
• Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.)
• Develop and participate in APP clinical development (Evidenced based care, professionalism, etc.)
• Lead and participate in high-risk huddles and ensure all patients discussed have a plan of care documented and includes all care management team members
• Build team-based culture and work collaboratively with clinical team members
• Conducts 10 chart audits per month or per state regulations, whichever is higher
• Act as resource for clinical team members for patient care questions/concerns and participate in difficult conversations with patients/family members as requested by team
• Routinely conduct panel reviews with APPs
• Sign DME, death certificates, and other orders as needed on behalf of APP (as regulated by state)
• Frequently review Quality metrics, pod level performance and identify areas for improvement leading to superior Quality (HEDIS) performance
• Frequently review clinician capacity and productivity performance. Partner with Site Medical Directors to develop countermeasures and support their implementation when provides are off track
• Work collaboratively with Regional Medical Director (RMD) to identify opportunities for care improvement
• Assist with service inquiry, resolution of patient complaints and requests for Pod as needed
• Assist pod providers to achieve higher EMR efficiency
• Participate in patient care to assigned panel and other patients as needed (High risk or complex patients, Physician face to face requirements, cognitive assessments, etc.)
• Participate and lead clinical education regarding accurate diagnosis, documentation and management of chronic conditions
• Assist with compliance and HR resolutions
• Responsible for discipline actions and performance reviews for direct reports
• Additional duties as assigned by the Regional Medical Director as related to clinical pod performance and outcomes.

Licensed Clinical Social Worker

• Manage a caseload of high-risk socially complex patients
• Conduct face to face and telephonic psychosocial assessments with the patient and/or the caregiver
• Investigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needs
• Provide short-term counseling services as needed
• Coordinate services to ensure the patient/family understands a treatment plan
• 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
• Provide outreach to community-based services to support the patient’s ability to age at home
• Develop and implement shared goals of care with the patient and family
• Work with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independence

• Conduct comprehensive in-home health risk assessments to identify all active and chronic disease conditions, as well as determine all physical, mental, and social needs present at the time of the visit
• Takes history, examines, determines diagnoses
• Provides written documentation of patient visit, per NCQA standards
• Takes patient vital signs, as necessary
• Places case management referrals and communicates with PCP as necessary
• Communicates with patients, caregivers, agency nurses, other providers and vendors as necessary to assure proper diagnosis
• Performs all clinical duties while observing OSHA Universal Precautions
• Maintains patient confidentiality
• Attends required meetings and in-services and participates in committees, as requested
• Participates in professional development activities and maintains professional licenses and affiliations

Nurse Practitioner – Per Visit Telehealth

General

• Chronic condition management of your own geriatric panel - spend 30-45min with your patients!
• Join our 250+ providers supporting over 85,000 high-risk Medicare patients across 39+ Medical Groups in 12 States
• Our clinicians are supported by an interdisciplinary team that makes it easier to focus on what matters most: delivering meaningful, patient-centered care.
• Our mobile care model allows providers to meet patients where they are, helping them stay healthier and more comfortable at home.
• Together, our teams are united by a shared mission to bring comfort, dignity, and peace to every patient while supporting one another along the way.

Advance Practice Provider, NP/PA – Primary Care

PRN Nurse Practitioner – Per Visit Telehealth

Pharmacist

• Provide clinical care to our home-based patient population in collaboration with our primary care team through comprehensive medication management
• Apply evidence-based medication use strategies to enhance patient and population health outcomes through appropriate medication therapies, transitions of care, and primary care pathways specific to disease management
• Maintain a high level of patient and care team satisfaction with exceptional customer service
• Perform as a highly dependable member of an interdisciplinary team
• Demonstrate working knowledge of current pharmaceutical literature and practice for patients served
• Quickly review patient records and other available information to identify and work to resolve potential drug therapy problems
• Actively participate in comprehensive medication reviews for patients
• Develop and implement monitoring and treatment plans in collaboration with the interdisciplinary care team
• Practice under collaborative agreements to make evidence-based adjustments to drug therapy for chronic disease management
• Provide patient and provider education related to optimization of medication therapy
• Ensure patient follow up and monitoring to improve disease management, quality, safety, and adherence
• Evaluate appropriateness and cost-effectiveness of drug therapy
• Communicate effectively with patients, providers, staff members, service teammates, and pharmacies
• Optimize care team pharmacist service workflows and processes to improve efficiencies and maximize clinical functionality
• Ensure maintenance of and adherence to established guidelines, policies and procedures related to medication management
• Maintain accurate and appropriate documentation within EMR
• Assist with report development and tracking of service metrics
• Reports adverse drug events and participates in medication quality improvement activities
• Provide training and education for practitioners and staff regarding evidence-based medication practices
• Assist the service, clinical team, regional chief medical officer, and operations partners with ad hoc projects and responsibilities as indicated
• Participate in the activities of various organizational standing and ad-hoc committees and develop pathways and policies related to medication management

Pharmacist – Care Team

Data Engineer

• The Senior Data Engineer is responsible for designing, developing, and optimizing scalable data infrastructure as well as tidy healthcare data products supporting advanced analytics and healthcare operations.
• Partner with end users and product team to translate business and user requirements into technical solutions using system thinking principles, ensuring performance, scalability, maintainability, security, and user experience
• Complete tasks using and lead by example with: Clean, well-documented, quality and efficient ETL code
• Well-architected scalable data models and code that scales via rules engine designs
• Debugging and troubleshooting complex data issues and provide timely solutions
• Contribution to improvement of DevOps and ProdOps with automation of builds, testing, deployment and monitoring
• Peer code reviews, mentoring and training junior team members
• Build scaled jobs and data integration solutions across platform types with best practice in security and network engineering
• Train other developers and stakeholders in adoption of new solutions
• Adherence to agile and scrum processes.
• Continuously improve technical skills and stay current with emerging technologies, integrating these into the platform and/or development processes to keep enhancing developer productivity and capabilities of the system.

Senior Data Engineer

• The Community Liaison is responsible for inbound/outbound communication and business development
• The role acts as the local market B2B, B2C, and D2C representative educating community partners and potential patients about the company, our mission and service offerings
• This role will help facilitate patient transitions of care from area facilities and referral partners to HarmonyCares
• Will explain the benefits of enrollment to eligible patients and caregivers
• Market analysis, along with competitive landscape, in which to differentiate HarmonyCares services to external referral partners
• Know and educate the community on our mission to provide high-quality personalized healthcare in the home for people that need it the most
• Meet or exceed agreed upon in person and virtual meeting goals with key decision makers
• Thoroughly understand eligibility and enrollment processes
• Provide education on and facilitate, as requested, benefit enrollment and processes
• Track performance in CRM demonstrating plan and adherence to budgeted targets for a given region
• Schedule face-to-face or phone discussions with patients and their caregivers (or other legal representatives) to provide guidance on patient eligibility for all programs
• For patients interested in being aligned or attributed to an accountable care organization (or other CMS alternative payment model), inform them about the program; if they opt to voluntarily align, collect Voluntary Alignment Form from patients (or their legal representatives)
• Answer inbound calls from patients, families, and facility staff members regarding the Company’s business units operating in the relevant market
• Promptly, accurately, professionally triage all patient concerns related to care needs, scheduling and billing to the appropriate department
• Oversee and document outreach calls conducted, and meetings scheduled with external sources
• Adhere to all company policies and procedures and all applicable laws and requirements

Community Liaison, Marketing and Business Development

Manager

• Coordinates care services with pod leader to ensure that patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey
• Works collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care
• Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly and to ensure that avoidable hospital admissions do not occur
• Coordinates and facilitates High Risk Huddles along with ensuring that follow-up actions are completed
• Prioritizes patients based on the severity and urgency of their conditions to ensure that the most critical cases receive immediate attention
• Reviews medical records to identify gaps in care and coordinate services with the care team to manage these issues
• Regularly updates patient care plans
• Performs thorough nursing assessments via telephone of patients to maximize or improve current health outcomes
• Provides education to patients and/or their caregivers on disease education, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes
• Demonstrates strong clinical skills, critical thinking abilities, and effective communication in their interactions with patients, caregivers, providers, fellow care team members, etc.
• Documents necessary interactions, assessments, updates, etc. in patient’s medical records according to processes and guidelines
• Serves as liaison between patients, providers, resources, etc. to ensure seamless care delivery
• Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home

PRN Nurse Practitioner – Telehealth

Medical Assistant, Clinical Partner

PRN Nurse Practitioner, Home Visits/Telehealth

Medical Assistant, Clinical Partner

Physician Leader – Primary Care

Community Liaison – Business Development

Physician Leader – Primary Care

Licensed Clinical Social Worker

Nurse Practitioner – Per Visit Telehealth

Advance Practice Provider, NP/PA – Primary Care

PRN Nurse Practitioner – Per Visit Telehealth

Pharmacist – Care Team

Senior Data Engineer

Community Liaison, Marketing and Business Development

RN Nurse Care Manager