Care Advocate - Care Delivery
About the role
Wider Circle works with health plans and providers nationally to deliver unique community care programs that connect neighbors for better health. Centered on trusted relationships, Wider Circle connects health plan members with like-minded neighbors to inform, support and motivate one another, empowering them to be more proactive about their health. Wider Circle’s trusted delivery network has been proven to drive resilience, improve member experience and engagement, and reduce inappropriate utilization and has been published in peer-reviewed literature. Today, Wider Circle offers its unique neighborhood care programs to tens of thousands of communities nationwide. To learn more, visit widercircle.com.
We are a mission-driven team dedicated to stabilizing high-risk populations and ensuring that no one falls through the cracks of the healthcare system. Our mission is to integrate Case Management, Care Navigation, and Benefits Enrollment into a single seamless layer of support with a focus on patients and their Social Determinants of Health (SDOH). This work bridges the gap between clinical requirements and social stability, and this role is vital to achieving that balance.
Responsibilities
- Principal Illness Navigation (PIN): Execute person-centered care plans for patients with serious, high-risk illnesses. Assist in monitoring and revising disease-specific plans, especially when frequent adjustments in medication or treatment regimens are required.
- Clinical Care Bridge: Act as the link between the patient and the billing practitioner. Support care coordination by managing provider availability, rescheduling, and providing post-hospital discharge support.
- SDOH Assessment & Goal Setting: Conduct person-centered assessments to understand the patient’s social and cultural context. Identify unmet social needs—such as food insecurity or housing instability—that impact the management of their serious condition and develop specific action plans to address them.
- System Navigation & Advocacy: Assist patients and caregivers in navigating the Pennsylvania healthcare landscape. Teach self-advocacy skills to help patients communicate effectively with specialists and coordinate transportation or access to telehealth.
- Technical & Workflow Support: Support patient communication templates and automation. Coordinate with the tech team to set up workflows, handle technical troubleshooting, and update patient charts in the Case Management System (CMS) with precision.
- Resource Coordination: Refer patients to supportive services and community-based resources. Establish and maintain partnerships with local Pennsylvania organizations to bring targeted resources (legal aid, food assistance, etc.) to our members' attention.
- Behavioral & Social Support: Use motivational interviewing and capacity-building to help patients manage the stress of chronic illness. Provide tailored education to improve treatment adherence and offer emotional support to families and caregivers.
- CMS Compliance & Documentation: Maintain detailed logs of all interactions, including the amount of time spent and specific activities performed. Ensure all documentation meets the standards required for Medicare clinical and social integration services.
Essential Functions
- PA Locality: Safely and consistently drive to public places and member homes within a 50-mile radius in Pennsylvania.
- Remote Independence: Successfully work in a remote team environment with high independence and minimal oversight.
- Physical Presence: Frequently carry up to 30 pounds of supplies and stand/walk for the duration of home visits or member interactions.
- Digital Literacy: Ability to use a computer, tablet, and smartphone to update data in multiple secure systems with accuracy.