Care Concierge

At Home Harmony's Care Concierge Team is made up of experienced RN, LPN and MA staff who are passionate about case management and clinical support for our home based medical and pharmacy practice for aging adults. The Care Concierge / RN works with their medical provider, the patients and their family members/caregivers to provide coordinated case management and medical support from a REMOTE environment - a hybrid workplace of company HQ, home and possible senior living community. Duties and Responsibilities of the Care Concierge / RN: Clinical Support (Remote via phone) Triaging patients over the phone Facilitating patient scheduling in EMR Recording patient information and data in the EMR Manage EMR inbox needs Return patient calls and provide consistent communication between medical provider, patient, other department leads and external partners. Order, track and post results for provider review of diagnostic testing Order DME Monitor remote patient tools such as blood pressure, pulse ox, etc. and contact patients based on clinical criteria for abnormal readings Other duties as requested Case Management (Remote via phone) This involves talking on the phone, utilization of computer programs such as EMR and additional systems, and, periodically, time at senior living communities or riding in vehicle to the place of service.  Create comprehensive and personalized care plans for enrolled patients Assists patients in transitions of care including hospital discharges, rehab admissions/discharges, scheduling follow-up appointments, assisting with home health orders and plan of cares, and other patient-specific needs May be required to complete in-person assessments in order to set up RPM devices Work with the AHH team of providers and other support staff to provide ongoing chronic care management to full panel of patients Provide education regarding disease management risk reduction, strategies and tactics. Complete concise, clear, timely documentation in the EMR and supporting software to meet documentation requirements. Promote At Home Harmony's Coordinated Model of Care of Medical and Pharmacy Job Requirements 5 years' experience in at least one of the following settings: case management, disease management, home health care, hospital or outpatient office setting Experience in Geriatrics, Family Practice, Internal Medicine, Cardiac or Pulmonary with a passion for working with the Geriatric population Current unrestricted VA license/certification, required Current BLS, required 2 years electronic medical record (EMR) experience Athena EMR, preferred Knowledge of chronic care monitoring/management, preferred Strong technology skills use of various systems Strong, professional oral and written communication skills Outgoing, adaptable and friendly personality Motivated and flexible to changing needs of the program, team and work environment, with ability to self-direct in certain prioritization of tasks Ability to efficiently work remotely and continue to meet productivity metrics Knowledge of physician office practice operations, preferred Valid drivers license with clean driving record Ability to lift and carry equipment up to 50 pounds Ability to walk up and down several flights of stairs easily At Home Harmony Launched in 2022, At Home Harmony is an innovative home-based Medical and Pharmacy practice in Richmond, VA providing exceptional healthcare for aging adults with complex chronic conditions. We are experts in utilizing Medicares comprehensive programming to provide coordinated top-quality care. If you are seeking a meaningful, flexible opportunity in a team-oriented environment, consider a role with us. Bring your ideas, knowledge, passion and dedication to our growing team and together we can make a difference in the lives of our beloved senior population.