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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 relationships to assist with social needs. The Guia works within a clinical setting and the community, partnering with medical providers, nurses, medical assistants, and the wider team to enhance 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, internal 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.
- 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.
- 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.
- 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 the daily operations of a primary care practice, including answering phone calls 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 relations 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.
- 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).
Skills
- Care coordination
- Patient engagement
- Health education
- Social needs assessment
- Community resource mobilization
- Electronic Medical Records (EMR) proficiency
- Microsoft Office Suite proficiency
- Therapeutic communication
- Team collaboration
- Intercultural communication
Location
- North Austin, TX
Work Type
- Onsite
- In-home
- Remote
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.