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About the Role

The Guia manages a patient panel within a multidisciplinary primary care team to address preventive, chronic, and acute care needs. This role focuses on building supportive relationships with patients and their families, empowering them to make healthy lifestyle choices, and assisting with social needs in both clinical and community settings.

Responsibilities

• Provide comprehensive care coordination for an assigned patient caseload.
• Collaborate with patients, families, caregivers, and healthcare providers to address complex social needs.
• Facilitate communication between multidisciplinary team members to ensure integrated care.
• Support patients and families regarding the emotional, social, and financial impacts of illness or disability.
• Conduct home visits as required by safety policies.
• Identify and mobilize family and community resources.
• Document all interventions accurately and timely in patient medical records.
• Onboard patients to the care model and manage care visits.
• Educate patients on acute and chronic disease management.
• Develop patient self-efficacy and confidence in health management.
• Communicate with patients via in-person, phone, video, and text channels.
• Maintain knowledge of Medicare, Medicaid, and other program benefits.
• Coordinate care across the continuum, including appointment scheduling and referrals.
• Participate in daily clinical operations and maintain clinical space.
• Track patient enrollment and progression through care programs.

Requirements

• 4-5 years of experience in a healthcare setting or relevant field.
• Expertise in connecting patients with community resources and government agencies.
• Experience managing the needs of senior and geriatric populations.
• Proficiency in completing benefit applications such as SNAP, LIS, PAP, and prescription assistance.
• Experience utilizing electronic medical records and social service referral software.
• Experience assessing and addressing social determinants of health.
• Ability to work in-home, in-clinic, and remotely.
• Bilingual and bicultural (English and Spanish).
• Community Health Worker certification.
• Bachelor's degree preferred.

Skills

• Care coordination
• Patient advocacy
• Therapeutic communication
• Organizational and time management
• EMR proficiency
• Microsoft Office Suite
• Cross-cultural communication
• Interdisciplinary collaboration

Experience Level

• 4-5 years of experience

Education Level

• Community Health Worker certification
• Bachelor's degree (preferred)

About the Company

• Suvida Healthcare

Equal Opportunity

• Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard 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.