Care Coordinator

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 Support This portion of the role will account for approximately 50% of overall responsibilities. Facilitate telehealth (TH) 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 provider Perform comprehensive nursing assessments and screenings, including vital signs, functional status, fall risk, cognitive concerns, and disease-specific assessments Provide clinically confident wound care, including assessment, treatment, dressing changes, monitoring for infection, and documentation Support medication management, including medication reconciliation, patient education, adherence support, and identification of potential medication-related concerns for provider review Provide 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 concerns Prepare, 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 team Participate in daily huddles and interdisciplinary team meetings Provide clinical support to senior living facilities partnered with At Home Harmony Care Coordination & Communication This portion of the role will account for approximately 50% of overall responsibilities. Coordinate patient scheduling, appointment reminders, and follow-up outreach Assist 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 results Support population health initiatives, chronic care management, and care coordination workflows Serve as a clinical liaison between patients, caregivers, providers, and partner organizations Job Requirements Active, unrestricted LPN license in the state of Virginia Candidates must be comfortable entering patient homes and performing clinical duties in a home-based care environment Clinical confidence in wound care, medication management, patient assessments, screenings, and chronic disease management Experience in Geriatrics, Family Practice, Internal Medicine, Cardiac, or Pulmonary care preferred, with a passion for serving aging adults Current BLS certification required Minimum of 2 years of electronic medical record (EMR) experience; Athena preferred Knowledge of chronic care monitoring and management preferred Strong technology skills and comfort using multiple systems Strong professional oral and written communication skills Outgoing, adaptable, and patient-centered demeanor Motivated, flexible, and able to self-direct and prioritize tasks independently Ability to work remotely while meeting productivity and quality metrics Knowledge of physician office practice operations preferred Schedule & Work Environment Monday–Friday, 8:00 AM – 4:30 PM Office-based during training and probationary period Eligible for partial remote work upon successful completion of probation, based on performance and departmental needs Compensation & Benefits Competitive hourly rate, commensurate with experience and licensure Paid time off and paid holidays Benefits package including health insurance and 401(k) Opportunities for professional growth within a fast-expanding, patient-centered care model About At Home Harmony Launched 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. #J-18808-Ljbffr