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About the Role

The Guia is responsible for a panel of patients, collaborating with a multidisciplinary primary care team to address preventive, chronic, and acute care needs. This role focuses on engaging patients, empowering them to actively manage their health through lifestyle choices and behaviors, and building trusting, supportive relationships with patients and their families. The Guia also assists patients with social needs, working within clinical and community settings alongside a diverse team 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 collaborative process and communication among healthcare team members, multidisciplinary teams, patients, families, and caregivers for integrated care services.
Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability.
Conducts in-person visits to the patient’s homes as needed, per the Home Safety Measures Policy.
Accesses and mobilizes family/community resources to meet social care needs.
Documents all interventions in the patient medical record timely and accurately, including clinic visits, in-home, telephonic engagement, or texting.
Onboards patients to the Suvida model 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.
Communicates with patients in-person, by phone, video conference, and text messaging.
Collaborates with other members of the multidisciplinary care team, including Guia manager, Transitions of Care managers, and Medicaid case managers.
Maintains knowledge of Medicare, Medicaid, and other program benefits to assist patients with resource allocation and choices.
Provides consultation and collaborates with other Guias and team members on patients with significant or intensive community resources needs.
Assists with the coordination of care across the continuum, such as scheduling appointments, coordinating referrals, and sharing information.
Participates broadly in daily primary care practice operations, including answering phone calls and messages and ensuring general upkeep of the clinical space.
Tracks patient enrollment and progression through care programs.
Performs other duties as assigned by the Guia Manager.

Requirements

4-5 years of experience working in a 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 and develop collaborative relationships with physicians, families, patients, interdisciplinary team members, and community agencies.
Strong organizational and time management skills, with the capacity to prioritize multiple tasks and role components.
Knowledge and expertise in completing benefit applications such as SNAP, LIS, PAP, and prescription assistance.
Effective oral and written communication skills.
Proficiency with EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite.
Experience utilizing electronic medical records and social service referral management software.
Experience assessing and addressing the social determinants of health.
Excellent therapeutic communication with patients, families, and caregivers.
Ability to articulate Suvida Healthcare’s mission in relation to patient satisfaction and patient outcomes.
Compassionate, kind, and open-minded demeanor.
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.
Bilingual/Bicultural (English and Spanish) proficiency.

Skills

Care coordination
Collaboration
Communication
Patient education
Resource mobilization
Documentation
EMR proficiency
Microsoft Office Suite
Therapeutic communication
Teamwork

Location

In-home
In-clinic
Remotely

Work Type

Full-time

Experience Level

4-5 years

Education Level

Bachelor's degree (preferred)
Community Health Worker certification

About the Company

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.

Equal Opportunity

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.