HarmonyCares

Manager

• The Nurse Care Manager is an integral member of the care team and is vital to enhancing the health outcomes of HCMG patients.
• This position will manage a caseload of high-risk patients where he/she is responsible for managing their care and barriers.
• These duties will include, but are not limited to Transitional Care Management, Chronic Care Management, Disease Management Education, Medication Education, and the development and management of patient care plans.
• The Nurse Care Manager will serve as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs to improve patient outcomes.
• 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.

Telephonic Nurse Care Manager

• Lead a team responsible for building and maintaining high quality foundational data products
• Oversee the end-to-end delivery of data products
• Manage a team responsible for the design, implementation, and maintenance of data products and processes for Value Based Care Payer Contracts
• Communicate with consumers regularly on data related processes
• Collaborate with other departments to gather data requirements and implement new payer contracts
• Co-create project goals and timelines across the team and with stakeholders
• Construct and execute a prioritization framework
• Develop a deep understanding of user needs and refine new solution features
• Counsel teams leveraging frameworks (e.g., scrum) focusing on data-driven prioritization and value-driven outcomes
• Demonstrate understanding of Acceptance Test Driven development, DevOps principles, data/system integration needs
• Leverage understanding of non-functional product requirements to build holistic roadmaps
• Monitor and troubleshoot data processing systems and infrastructure

Manager – Enterprise Data Services

Risk

• 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

Per-Visit Nurse Practitioner – Health Risk Assessments

Bilingual

• Placing a high volume of outbound calls to secure an appointment with a licensed Nurse Practitioner
• Answer incoming calls from members and case managers as well as return voice mail messages
• Contact Health Plan members via provided lists to secure appointments
• Follow specific talking points and protocols for outreach
• Secure visits via scheduling software efficiently
• Demonstrate excellent customer service skills at all times
• Utilize exceptional communication and social skills to explain the importance of annual assessment
• Conduct follow-up calls to members prior to scheduled dates
• Confirm and verify demographic and contact information
• Verify member’s insurance active status and accurately enter the insurance information
• Escalate problems or concerns associated with field providers to the manager
• Meet set performance standards and departmental goals

Outreach Specialist, Bilingual Spanish

Analyst

• Develop and maintain provider schedules to meet patient needs
• Manage provider census through proactive census risk management
• Manage market census to ensure the right patients are seen at the right time based on HarmonyCares risk tiering and inactivation process
• Collaborate with local leadership to maximize scheduling system and ensure patient requests are communicated
• Maintain relationships and effectively communicate HarmonyCares services with patients and family members
• Place and receive phone calls to facilitate effective scheduling function
• Escalate scheduling concerns, and issues, both internally and externally
• Adhere to patient confidentiality policies and procedures
• Attend required meetings and in-services
• Collaborate with manager, teammates, and other HarmonyCares employees
• Perform other duties as required

Scheduling Analyst

• Develop and maintain provider schedules to meet patient needs.
• Manage provider census through proactive census risk management.
• Manage market census to ensure the right patients are seen at the right time based on HarmonyCares risk tiering and inactivation process.
• Collaborate with local leadership to maximize scheduling system and ensure patient requests are communicated.
• Maintain relationships and effectively communicate HarmonyCares services with patients and family members.
• Place and receive phone calls to facilitate effective scheduling function.
• Escalate scheduling concerns, and issues, both internally and externally
• Adhere to patient confidentiality policies and procedures.
• Attend required meetings and in-services.
• Collaborate with manager, teammates, and other HarmonyCares employees.
• Perform other duties as required.

• Scheduling optimization and census management
• Assist in day-to-day market scheduling as directed by market operations leader
• Conduct daily outreach efforts via phone, mailing campaigns and in person interventions to reschedule, retain and recover patients that have been lost in follow-up or at risk
• Design, implement, and conduct new and innovative patient retention, recovery, engagement, and outreach strategies for those patients who are at risk, without a scheduled visit and refusing HC services in effort to increase patient retention
• Analyze patients at risk and those refusing services using data analysis and action planning for retention and census growth leading to increased patients scheduled and reduced at risk patients
• Analyze data on daily basis to monitor trends and decrease patient loss through interventions with clinical and operational leadership
• Conduct needs assessment of market interventions required to enhance patient experience and patient retention and conduct training and individual mentorship for all team members in positive patient retention strategies and overcoming patient objections
• Mentor, train, and coach for patient retention and patient-focused communication
• Manage complex, real-time operational challenges related to scheduling and patient retention

Scheduling Analyst, Patient Retention, Recovery

• 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 patients' 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

Telephonic RN Nurse Care Manager, Wisconsin

• Schedule and perform home visits to collect Health Risk Assessment (HRA) data, unless request to obtain telephonically
• Communicate any patient needs timely with Nurse Manager in effort to expedite process of getting the patient needs fulfilled
• Maintain accurate records providing detail of calls attempted and telephonic HRA

Health Risk Assessment Nurse, Licensed Practical Nurse (LPN)

• 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

RN Nurse Care Manager – Telephonic

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

Human Resources

• Serve as a first point of contact for employee HR inquiries, providing timely, accurate, and proactive customer service
• Manage and process high volume HR administrative tasks while maintaining accuracy and attention to detail
• Support I 9 processing and employment verification in compliance with federal requirements
• Manage HR ticketing and intake requests, including monitoring incoming requests, responding where appropriate, and routing items to the correct HR owner or functional team.
• Assist with benefits administration, including employee questions, enrollment support, and coordination with internal partners
• Maintain accurate employee records within HR systems and ensure data integrity
• Utilize Microsoft Office tools including Excel, Word, Outlook, and Teams to track work, manage documentation, communicate updates, and support reporting needs
• Communicate clearly and professionally with employees, HR partners, and internal stakeholders
• Identify opportunities to improve the employee experience and flag trends or recurring issues to HR leadership
• Support ongoing HR initiatives, audits, and process improvements as needed
• Demonstrates a proactive, service-oriented mindset when supporting employees, responding with empathy, professionalism, and a solutions-focused approach while maintaining confidentiality and trust
• Explain HR processes and next steps in a way that is easy for employees to understand, even in high-volume situations
• Manages multiple tasks and priorities simultaneously while meeting deadlines
• Effectively tracks work, follows through on open items, and maintains clear documentation
• Demonstrates urgency and reliability in responding to employee inquiries and HR intake requests
• Ensures issues are appropriately routed, monitored, and closed with clear communication
• Understands when to resolve issues independently and when to escalate to the appropriate HR partner

HR Employee Services Specialist

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
• 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

Clinical Partner, Medical Assistant

• 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
• 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

• 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 are 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