Community Health Navigator & Care Coordinator

Suvida Healthcare; Dallas (TX); On-site; USD 42,000 - 65,000; Full time

Job summary

Suvida Healthcare seeks a Guia to coordinate care for a panel of patients within a multidisciplinary primary care team. You will establish trusting relationships, assist with social needs, and support patients in managing health at home, in clinic, and remotely.

You will collaborate with physicians, nurses, and coordinators to ensure integrated care, while guiding patients through benefits and community resources to improve outcomes.

Qualifications

• 4-5 years in healthcare or relevant experience.
• Expertise connecting patients with community resources and governmental agencies.
• Experience managing senior/geriatric populations.
• Ability to work independently and collaboratively with clinicians and families.
• Strong organizational and time management skills.

Responsibilities

• Provide comprehensive care coordination for an assigned patient caseload.
• Collaborate with patients, families, caregivers, healthcare providers, and external partners to meet complex social needs.
• Promote integrated care through collaboration and clear communication among care teams.
• Intervene with patients and families regarding emotional, social, and financial consequences of illness.
• Conduct in-person home visits as needed and per policy.
• Access and mobilize family/community resources to meet social care needs.
• Document all interventions timely in the medical record across settings.
• Onboard patients to the Suvida model and care visits.
• Educate patients on acute and chronic disease management.
• Guide patients and families in care planning and self-management.
• Establish healing relationships with patients and families.
• Communicate with patients via in-person, phone, video, and text.
• Coordinate with Guia Manager and care team members on resource needs.
• Assist with scheduling, referrals, and information sharing across care teams.
• Participate in daily operations and patient enrollment tracking.

Skills

Patient coordination

Closed-loop referrals

Senior/geriatric care

Independent & collaborative work

Time management

Benefits applications (SNAP/LIS/PAP)

Communication skills

EMR proficiency

Referral management software

Education

CHW certification (preferred)

Bachelor’s degree (preferred)

Tools

EMR systems

Microsoft Office

Referral management software

Job description

Suvida Healthcare seeks a Guia to coordinate care for a panel of patients within a multidisciplinary primary care team. You will establish trusting relationships, assist with social needs, and support patients in managing health at home, in clinic, and remotely.

You will collaborate with physicians, nurses, and coordinators to ensure integrated care, while guiding patients through benefits and community resources to improve outcomes.