Community Health Worker

Suvida Healthcare; United States; On-site; USD 42,000 - 54,000; Full time

Job summary

Suvida Healthcare is seeking a Guia to provide comprehensive care coordination for a patient caseload within a multidisciplinary primary care setting. The role emphasizes partnerships with patients, families, and community resources to address social determinants of health and ensure integrated care.

The Guia will conduct in-home visits as needed, onboard patients to the Suvida model, and educate on disease management.

Qualifications

• 4–5 years of experience in healthcare setting or relevant experience.
• Expertise connecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs.
• Experience managing the needs of Senior/Geriatric populations.
• Ability to work independently while developing collaborative relations with physicians, families, patients, interdisciplinary team members, and community agencies.
• Strong organizational and time management skills, evidenced by capacity to prioritize multiple tasks.

Responsibilities

• Provides comprehensive care coordination to an assigned patient caseload.
• Works collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex social needs.
• Promotes a collaborative process and communication between all healthcare team members to ensure integrated care services are targeted and beneficial.
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness.
• Conducts in-person visits to the patient’s homes, as needed.
• Accesses and mobilizes family/community resources to meet social care needs.
• Documents all interventions in the patient medical record timely and accurately.
• Onboards patients to the Suvida model and their medical/social care visits.
• Provides patient education on acute and chronic disease management.
• Guides patients and families.
• Establishes healing relationships with patients and families.
• Employs confidence-promoting techniques to improve patient self-efficacy.
• Communicates with patients in-person and by phone, video, and text.
• Collaborates with the Guia Manager and Medicaid case managers.
• Maintains knowledge of Medicare, Medicaid, and other program benefits.
• Provides consultation with Guias on patients needing intensive community resources.
• Assists with arranging care across the continuum (appointments, referrals, information sharing).
• Participates in daily operations of a primary care practice (phone calls, space upkeep).
• Tracks patient enrollment and progression through care programs.

Skills

Healthcare experience

Care coordination

Senior/Geriatric care

Independent work

Organizational skills

Benefit applications (SNAP LIS PAP)

Communication skills

EMR proficiency

Social determinants of health

Cultural competence

Education

CHW certification (preferred)

Bachelor’s degree (preferred)

Tools

EMR systems

Microsoft Office

Referral management software

Job description

What You’ll Do

Position Summary

The Guiais responsible fora panel of patients and, in collaboration with other members of a multidisciplinary primary care team, helps patients meet their preventive, chronic, and acute care needs. The Guia engages patients and encourages them to take an active role in their health by providing the tools necessary to make healthy lifestyle choices and adopt lifelong healthy behaviors. This individual’s primary responsibilities center aroundestablishingtrusting, supportive, collaborative relationships with patients and their families andassistingpatients in meeting their social needs. The Guia builds relationships with patients in a clinical setting and in the community by working alongside medical providers, nurses, medical assistants, and a multidisciplinary team in a collaborative and empathetic team approach to improve patient outcomes.

Responsibilities

• Provides comprehensive care coordination to an assigned patient caseload

• Works collaboratively with patients, family, caregivers, healthcare providers, and external partners, to meet complex social needs

• Promotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and caregivers to ensure the process of integrated care services are targeted,appropriate, and beneficial

• Intervenes with patients and familiesregardingemotional, social, and financial consequences of illness and/or disability

• Conducts in-person visits to the patient’s homes, as needed,perthe Home Safety Measures Policy.

• Accesses and mobilizes family/community resources to meet social care needs

• Documents all interventions in the patient medical record bothtimelyand accurately including all elements of clinic visits, in home, telephonic engagement, or texting

• Onboards patients to theSuvidamodel and their medical/social care visits

• Provides patient education on acute and chronic disease management

• Provides guidance to patients and families

• Establishes healing relationships with patients and families

• Employs confidence-promoting techniques in patient communication and develops patient self-efficacy to better manage health

• Communicates with patients in-person and by phone, video conference, and text messaging

• Collaborates with other members of the multidisciplinary care team including but not limited to the Guia manager, Transitions of Care managers, and Medicaid case managers

• Maintains knowledge of Medicare, Medicaid, and other program benefits toassistpatients with resource allocation and choices

• Provides consultation and collaborates with other Guias and team members on patients with significant or intensive community resourcesneeds

• Assistswith the coordination of care across the continuum,such as:scheduling appointments with providers, coordinating referrals, and sharing or transferring information with the patient’s internal and external care team

• Participates broadly in the daily operations of a primary care practice, such as: Answering incoming phone calls and messages and ensuring general upkeep of the clinical space

• Tracks patient enrollment and progression through care programs

• Other duties as assigned by the Guia Manager

Knowledge, Skills, and Abilities

• 4-5 years of experience working in healthcare setting or relevant experience

• Expertiseconnecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs

• Experience managing the needs of Senior/Geriatric populations

• Ability to work independently, as well as, to develop collaborative relations with physicians, families, patients, interdisciplinary team members, and community agencies

• Strong organizational and time management skills, asevidencedby capacity to prioritize multiple tasks and role components

• Possess knowledge andexpertisein completing benefit applications such as SNAP, LIS, PAP, and prescriptionassistance

• Effective oral and written communication skills

• Proficiencywith EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite

• Experienceutilizingelectronic medical records and social service referral management software

• Experience assessing and addressing the social determinantsof health

• Excellenttherapeutic communicationwith patients,families, and caregivers

• Able to articulate Suvida Healthcare’s mission in relation to patient satisfaction and patient outcomes

• Compassionate, kind, and open-minded

• Teamwork experience

• Ability to communicate and effectively interact with people across cultures, ranges of ability, genders, ethnicities,and races.

• Able to care for patients in-home, in-clinic, and remotely.

Education, Experience, Licensure, or Certification Requirements

• CHW certification(preferred)

• Bachelor’s degree (preferred)

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any typewithregard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.