Community Health Worker - Suvida Healthcare LLC

• Earn Trust
• Building Relationships
• Creating Joy
• Doing Right
• Improving Every Day
• Moving Forward

• 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
  
  

• 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)

• CHW certification

• Bachelor"s degree (preferred)

PI248408253