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Full-time
bachelor degree, professional certificate
Posted 11d ago
~40 hrs/week
Responsibilities
The Guia provides comprehensive care coordination for a panel of patients, working within a multidisciplinary team to address medical and social needs. Responsibilities include conducting home visits, managing patient documentation, and facilitating access to community and governmental resources.
Requirements
Candidates must have 4-5 years of healthcare experience and a Community Health Worker certification. Proficiency in Spanish and English is required, along with experience in EMR systems and managing care for geriatric populations.
Full job description
What You’ll 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 individual’s 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 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 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 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 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
What You’ll 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 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)
Education, Experience, Licensure, or Certification Requirements
Community Health Worker certification
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 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.
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.
Related keywords
Community Health WorkerCare CoordinationSocial Determinants of HealthGeriatric CareEMRMedicareMedicaidSNAPPatient AdvocacyChronic Disease ManagementHome SafetyBilingualCase ManagementPrimary CareMultidisciplinary TeamPatient Education
How many Social Services jobs are open in Austin, TX right now?
There are currently 1,368 open social services positions in Austin, TX listed on Clera. New openings are added daily as companies post roles.
Which companies are hiring for Social Services roles in Austin, TX?
Companies currently hiring include Texas Department of State Health Services, Goodwill Central Texas, Aiken Regional Medical Centers, Foundation Communities, Greater Austin YMCA, among others. Browse the listings above to see every active employer.
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