Care Coordinator

Care Facilitator – Nurse (LPN)At Home Harmony's Clinical Team is comprised of experienced RNs, LPNs, and Medical Assistants who are passionate about case management and clinical support for our home-based medical and pharmacy practice serving aging adults.At Home Harmony is seeking a clinically confident, organized, and patient-centered Care Facilitator – Nurse (LPN) to support our growing practice. This role is critical to delivering high-quality in-home and virtual care, supporting providers during telehealth visits, and ensuring effective care coordination for patients with complex chronic conditions. The ideal candidate is adaptable, compassionate, and confident working independently in a home-based environment.Patient & Provider SupportThis portion of the role will account for approximately 50% of overall responsibilities.Facilitate telehealth visits by being present in the patients home to support the patient while the provider conducts the visit remotely, including technology setup, clinical assistance, patient assessment, and real-time communication with the providerPerform comprehensive nursing assessments and screenings, including vital signs, functional status, fall risk, cognitive concerns, and disease-specific assessmentsProvide clinically confident wound care, including assessment, treatment, dressing changes, monitoring for infection, and documentationSupport medication management, including medication reconciliation, patient education, adherence support, and identification of potential medication-related concerns for provider reviewProvide disease management support and patient/caregiver education for chronic conditions (e.g., heart failure, diabetes, COPD, hypertension, dementia)Conduct telephonic patient check-ins prior to scheduled visits to assess health changes, review medications and allergies, and identify clinical concernsPrepare, review, and upload all pre-visit documentation into the EMR (Athena)Review hospital discharges and transitions of care, communicating key updates and concerns to the provider teamParticipate in daily huddles and interdisciplinary team meetingsProvide clinical support to senior living facilities partnered with At Home HarmonyCare Coordination & CommunicationThis portion of the role will account for approximately 50% of overall responsibilities.Coordinate patient scheduling, appointment reminders, and follow-up outreachAssist with incoming patient calls, clinical messages, and coordination with internal departments (pharmacy, personal care, GUIDE program, etc.)Track labs, imaging, and referrals; ensure timely follow-up and communication of resultsSupport population health initiatives, chronic care management, and care coordination workflowsServe as a clinical liaison between patients, caregivers, providers, and partner organizationsJob RequirementsActive, unrestricted LPN license in the state of VirginiaCandidates must be comfortable entering patient homes and performing clinical duties in a home-based care environmentClinical confidence in wound care, medication management, patient assessments, screenings, and chronic disease managementExperience in Geriatrics, Family Practice, Internal Medicine, Cardiac, or Pulmonary care preferred, with a passion for serving aging adultsCurrent BLS certification requiredMinimum of 2 years of electronic medical record (EMR) experience; Athena preferredKnowledge of chronic care monitoring and management preferredStrong technology skills and comfort using multiple systemsStrong professional oral and written communication skillsOutgoing, adaptable, and patient-centered demeanorMotivated, flexible, and able to self-direct and prioritize tasks independentlyAbility to work remotely while meeting productivity and quality metricsKnowledge of physician office practice operations preferredSchedule & Work EnvironmentMonday–Friday, 8:00 AM – 4:30 PMOffice-based during training and probationary periodEligible for partial remote work upon successful completion of probation, based on performance and departmental needsCompensation & BenefitsCompetitive hourly rate, commensurate with experience and licensurePaid time off and paid holidaysBenefits package including health insurance and 401(k)Opportunities for professional growth within a fast-expanding, patient-centered care modelAbout At Home HarmonyLaunched in 2022, At Home Harmony is an innovative home-based Medical and Pharmacy practice in Richmond, VA, providing exceptional healthcare to aging adults with complex chronic conditions. We specialize in leveraging Medicare's comprehensive programs to deliver coordinated, high-quality care directly in the home.If you are seeking a meaningful, flexible opportunity in a collaborative and mission-driven environment, we invite you to join our team. Bring your clinical expertise, compassion, and dedication — together, we can make a meaningful difference in the lives of our senior population. Lange Recruiting