Community Health Worker

What Youll Do

Position Summary

The Guia is responsible for a 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 individuals primary responsibilities center around establishing trusting supportive collaborative relationships with patients and their families and assisting patients 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. Essential responsibilities consist of but not all inclusive:

Responsibilities

• Provides comprehensive care coordination toan 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 families regarding emotional social and financial consequences of illness and/or disability.
• Conducts in-person visits to the patients 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 both timely and accurately including all elements of 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 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 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 with providers coordinating referrals and sharing or transferring information with the patients 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

What Youll Bring

Knowledge Skills and Abilities

• 4-5 years of experience working 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 as well as to develop collaborative relations with physicians families patients interdisciplinary team members and community agencies.
• Strong organizational and time management skills as evidenced by capacity to prioritize multiple tasks and role components.
• Possess 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
• Able to articulate Suvida Healthcares 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)

Education Experience Licensure or Certification Requirements

• Community Health Worker certification
• Bachelors 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.

Required Experience:

IC