Bilingual Community Health Worker

Suvida Healthcare•Houston, TX

111d

About The Position

The Guia is responsible for an assigned patient panel and works with a multidisciplinary primary care team to help patients meet preventive, chronic, and acute care needs. The role encourages patients to take an active role in their health by providing tools for healthy lifestyle choices and lifelong healthy behaviors. A central focus is building trusting, supportive, collaborative relationships with patients and families and helping patients meet social needs. Guias work with medical providers, nurses, medical assistants, and other team members in clinical and community settings to improve patient outcomes.

Requirements

4–5 years of experience working in a healthcare setting or relevant experience.
Expertise connecting patients with community resources and governmental agencies and ensuring closed-loop referrals for complex social needs.
Experience managing the needs of senior or geriatric populations.
Ability to work independently and build collaborative relationships with physicians, families, patients, interdisciplinary team members, and community agencies.
Strong organizational and time-management skills, including the ability to prioritize multiple tasks and role components.
Knowledge and expertise 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 using electronic medical records and social service referral management software.
Experience assessing and addressing social determinants of health.
Excellent therapeutic communication skills with patients, families, and caregivers.
Ability to articulate Suvida Healthcare’s mission in relation to patient satisfaction and patient outcomes.
Compassionate, kind, and open-minded approach.
Teamwork experience.
Ability to communicate and interact effectively with people across cultures, ranges of ability, genders, ethnicities, and races.
Ability to care for patients in their homes, in clinic, and remotely.
Bilingual and bicultural in English and Spanish.
Community Health Worker certification.

Nice To Haves

Bachelor’s degree (preferred).

Responsibilities

Provide comprehensive care coordination to an assigned patient caseload.
Work with patients, families, caregivers, healthcare providers, and external partners to address complex social needs.
Promote collaboration and communication among healthcare team members, patients, families, and caregivers to ensure integrated care services are targeted, appropriate, and beneficial.
Address the emotional, social, and financial consequences of illness or disability with patients and families.
Conduct in-person visits to patients’ homes as needed, in accordance with the Home Safety Measures Policy.
Access and mobilize family and community resources to meet social care needs.
Document interventions promptly and accurately in patient medical records, including clinic visits, home visits, phone engagement, and text communication.
Onboard patients to the Suvida model and medical and social care visits.
Educate patients about acute and chronic disease management and provide guidance to patients and families.
Establish healing relationships and use confidence-promoting communication to develop patients’ self-efficacy in managing their health.
Communicate with patients in person, by phone, by video conference, and by text message.
Collaborate with the multidisciplinary care team, including the Guia manager, Transitions of Care managers, and Medicaid case managers.
Maintain knowledge of Medicare, Medicaid, and other program benefits to help patients make resource-allocation choices.
Consult and collaborate with other Guias and team members on patients with significant or intensive community resource needs.
Coordinate care across the continuum, including scheduling provider appointments, coordinating referrals, and sharing or transferring information with internal and external care teams.
Participate in daily primary care practice operations, including answering incoming calls and messages and maintaining the clinical space.
Track patient enrollment and progression through care programs.
Perform other duties as assigned by the Guia Manager.