Your Role

As a Care Management Coordinator, you will be a member of the patient’s interdisciplinary care team and will assist fellow team members and patients and/or their families or caregivers to help achieve their health goals ensuring the highest quality of safe care delivery. You will help coordinate patients' treatment plans, and connect them with health care, community resources, and their providers. In this role, you will complete tasks and activities that support Honest Health’s clinical programs, including care transitions and longitudinal care management.

Primary Functions Include:

• Establish trusting, supportive, and collaborative relationships with patients, family/caregivers, primary care practice staff, and the Honest interdisciplinary team (IDT).
• Build relationships with patients and/or caregivers telephonically and with internal and external care team members, including physicians, nurse practitioners, registered nurse care managers, social workers, pharmacists, transition of care coordinators, and other members of the IDT.
• Assist with the coordination of the patient’s care across the continuum, including activities such as requesting records and scheduling appointments with specialists, coordinating referrals, connecting with community resources, sharing or transferring information with the patient’s internal and external care team, retrieving records from the health information exchange, etc.
• Regularly monitor your assigned patients’ progress, track care plan milestones, and partner with IDT members to adjust care strategies as needed to ensure desired health outcomes.
• Provide ongoing patient follow-ups and reassessments using care best practices and Honest guidelines to ensure continuity of care.
• Communicate with patients by phone, monitor adherence to patient specific goals and care plans or in-person and escalate to the IDT when necessary.
• Complete assessments with patients or caregivers (post-discharge, PHQ2/9, SDOH screenings, etc.)
• When needed, schedule Honest providers’ home visits according to current practice. Complete reminder calls for scheduled home visits.
• Coordinate or create referrals for services or durable medical equipment, as directed by a registered nurse care manager or provider.
• Ensure annual wellness visits (AWVs) are scheduled within acceptable timeframes.
• Actively participate in Honest Health huddles and IDT meetings.
• Document and maintain accurate patient records and meeting minutes, as requested.
• Perform other related duties as assigned.

How You Qualify

You reviewed the Who You Are section of this job posting and immediately felt the need to read on. This makes you a match for our innovative culture. You accept things change quickly in a startup environment and are willing to pivot quickly on priorities.

• High school diploma or GED, required; Associates degree considered a plus
• Certified Medical Assistant (CMA) or Certified Nursing Assistant (CNA) or Health Coach Certification required
• Licensed Practical Nurse (LPN) certification preferred
• Prior work experience in a healthcare service environment required
• Prior experience with electronic health records or health registries required
• Prior experience working as part of an interdisciplinary care team preferred
• Prior experience communicating with and educating patients about their health goals and available resources
• Abe to learn new technologies and related processes and workflows, as well as contribute to process improvements when needed
• Strong Interpersonal communication skills with exceptional empathetic listening abilities
• Able to adapt with positivity
• Highly organized, able to prioritize work and multi-task
• Excellent telephonic, written, and verbal communication skills required
• Microsoft Office skills, including Excel, Word, PowerPoint, Outlook required, PowerPoint preferred

The base pay range for this role is $25.72 - $28.89/ hour. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, and organizational needs. Base pay is just one piece of the total rewards program offered by Honest. Eligible roles also qualify for short-term incentives and a comprehensive benefits package.