Community Health Worker

What Makes Us Unique

We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve.

What You’ll Do

• 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.
• 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.

What You’ll Bring

• Education Requirements: CHW certification (preferred), Bachelor's degree (preferred).
• Experience Requirements: 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 required (English and Spanish).