Healthguide - Community Resource

Guidehealth•Atlanta, GA

2d•Remote

About The Position

The Community Resource Guide is a key member of Guidehealth’s care delivery model, serving as a bridge between patients, primary care physicians, specialty providers, community resources, and the Guidehealth clinical team. This role blends patient navigation, care coordination, community resource connection, and foundational health and well-being support to help patients overcome barriers to care and progress toward improved health outcomes. The Community Resource Guide engages patients remotely and, at times, in person to help them understand their health needs, navigate medical, behavioral health, substance use, and social systems, close gaps in care, and access appropriate resources. This role supports whole-person health by building trusting relationships, addressing social drivers of health, coordinating services, and escalating emerging needs through established workflows. The Community Resource Guide contributes to Guidehealth’s value-based care performance by supporting quality outcomes, reducing avoidable utilization, improving patient engagement, supporting risk adjustment accuracy, and influencing total cost of care through proactive, compassionate, and efficient care navigation.

Requirements

At least 3 years of related experience in patient navigation, community resource navigation, medical assistance, health promotion, care coordination, peer support, emergency medical services, or a similar role.
Experience working directly with patients in clinical, community-based, or non-clinical settings, preferably with patients who have complex medical, behavioral health, social, or financial needs.
Experience using EHR systems or similar documentation platforms.
Demonstrated ability to work effectively in a remote environment.
Knowledge of medical terminology, primary care workflows, referral processes, and social drivers of health.
Strong critical thinking, problem-solving, and decision-making skills.
Strong verbal, written, listening, and documentation skills.
Ability to prioritize multiple tasks, manage time effectively, and work independently.
Familiarity with motivational interviewing, behavior change principles, patient education, or care navigation techniques.
Strong customer-service orientation with the ability to communicate with diplomacy, tact, empathy, and professionalism.
Ability to collaborate effectively with patients, families, caregivers, providers, community partners, and interdisciplinary care teams.
Ability to maintain confidentiality and comply with HIPAA, PHI security, and Guidehealth privacy requirements.

Nice To Haves

Community Health Worker certification or equivalent community health experience, when permissible by contract.
Peer Support Specialist certification or related peer support experience, when permissible by contract.
Emergency Medical Technician certification or related emergency medical services experience, when permissible by contract.
Experience supporting value-based care, population health, care gap closure, quality performance, risk adjustment, or total cost of care initiatives.
Experience working with high-risk patient populations or patients with complex medical, behavioral health, substance use, social, or financial needs.
Experience with referral coordination, transportation resources, community-based organizations, prior authorizations, or resource navigation.
Experience using EHR platforms such as Epic, Athena, Cerner, or similar systems.
Experience using patient engagement technology, analytics tools, patient portals, Microsoft Office, or AI-enabled outreach tools.
Bilingual skills, if aligned with patient population needs.

Responsibilities

Building trusting, ongoing relationships with patients, families, caregivers, medical providers, behavioral health providers, and community partners.
Engaging high-risk or targeted patient populations through bi-directional communication to address health questions, concerns, barriers, and care needs.
Identifying and assessing medical, behavioral health, substance use, social, emotional, and financial needs to support whole-person care.
Supporting patients in understanding and following care plans, health goals, preventive care needs, and recommended follow-up.
Providing patient education and motivational interviewing support within role scope to encourage engagement, adherence, and behavior change.
Conducting non-clinical assessments, surveys, and interventions to help patients navigate medical, behavioral health, substance use, and social systems.
Using multiple communication methods, including phone, text, video visits, patient portals, email, and AI-enabled engagement tools, to engage and support patients.
Recognizing and escalating changes in patient condition, adherence risks, social needs, or emerging clinical concerns using structured workflows.
Applying foundational clinical and care navigation insight to identify high-risk trends and prioritize interventions.
Operating within a value-based care model, supporting population health strategies, quality performance, and efficient resource utilization across assigned patient panels.
Strengthening connections between patients and their healthcare providers by addressing barriers, facilitating communication, and coordinating follow-up.
Assisting patients with referrals, transportation resources, appointment scheduling, specialty care access, and linkage to community-based organizations.
Using knowledge of referral processes, prior authorizations, gaps in care, social drivers of health, and community programs to support improved patient outcomes.
Escalating medical, behavioral health, social, or care coordination concerns appropriately to RN Care Managers, Social Workers, primary care offices, Guidehealth leadership, or other designated resources.
Supporting achievement of quality measures, including eCQM, HEDIS®, preventive care, chronic condition management, and commercial payer measures, by coordinating preventive screenings and timely follow-up care.
Supporting risk adjustment and accurate capture of patient conditions through structured assessments and documentation.
Assisting in closing care gaps tied to quality incentives, reimbursement models, and value-based care outcomes.
Identifying opportunities to reduce avoidable emergency department visits, hospitalizations, and readmissions through proactive outreach and intervention.
Accurately and promptly documenting all interactions, assessments, interventions, referrals, escalations, and outcomes in the electronic health record and Guidehealth documentation systems.
Using various EHR platforms, such as Epic, Athena, Cerner, or other systems, along with analytics tools, Microsoft Office, and Guidehealth applications.
Managing referrals, tracking tasks, completing reconciliations, and maintaining detailed records according to Guidehealth policies and procedures.
Supporting technology-enabled workflows, including AI-enabled outreach to identified populations.
Maintaining accurate documentation to support care coordination, quality performance, risk adjustment, and compliance requirements.
Working independently while collaborating closely with Guidehealth care management teams, medical practice staff, behavioral health partners, community partners, and other internal teams.
Participating in Guidehealth meetings, training sessions, quality-of-care initiatives, and process improvement activities.
Meeting and exceeding key performance indicators related to patient engagement and retention, quality measure performance, reduction in total cost of care, and timely completion of care coordination activities.
Communicating patient barriers, system gaps, resource needs, and operational opportunities to leadership and appropriate team members.
Maintaining professionalism, empathy, cultural competence, diplomacy, and sound judgment in all interactions.
Following all HIPAA, PHI security, privacy, and Guidehealth compliance policies.
Serving as a subject matter resource for workflows, documentation standards, patient engagement strategies, and community resource navigation.
Participating in process improvement initiatives, including workflow optimization, quality improvement projects, and care coordination best practices.
Supporting onboarding, mentoring, and training of new Community Resource Guides, as needed.
Providing feedback to leadership regarding system gaps, patient barriers, workflow challenges, and operational improvement opportunities.
Assisting in the development of best practices for documentation, outreach, community resource navigation, and care coordination.
Performing other duties as assigned.