Community Health Worker (Bilingual)

Company Description

Suvida Healthcare is a neighborhood-centric, multidisciplinary primary care program built to address the physical, behavioral, social, and cultural needs of the underserved Medicare-eligible Hispanic population. Multigenerational in design, Suvida’s differentiated approach will enable us to deliver on the quadruple aim, improving health outcomes as well as consumer and employee experience while lowering total cost of care. Suvida will thoughtfully cultivate an empathetic and service-centric environment, positioning us not only as a best-in class health care provider, but also as the provider of choice for our patients, their families, and the community at large.

Our Purpose

We are an empowered primary care team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and the neighborhoods we serve.

Our Vision

To improve the quality of life for underserved people and those that care for them in neighborhoods across America.

Job Summary

The Community Health Worker (CHW) is responsible for a panel of patients and, in collaboration with other members of a multidisciplinary primary care team, helps patients meet their preventive, chronic, and acute care needs. The CHW engages patients and encourages them to take an active role in their health by providing the tools necessary to make healthy lifestyle choices and adopt lifelong healthy behaviors. This individual’s primary responsibilities center around establishing trusting, supportive, collaborative relationships with patients and their families and assisting patients in meeting their social needs. The CHW builds relationships with patients in a clinical setting and in the community by working alongside medical providers, nurses, medical assistants, and a multidisciplinary team in a collaborative and empathetic team approach to improve patient outcomes.

Essential responsibilities consist of but not all inclusive:

• 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 to low risk guias 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

Education Requirements

• CHW certification
• 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
• Teamwork and management of personnel experience
• 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 determinant of health
• Excellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues
• Able to articulate Suvida Healthcare’s mission in relation to patient satisfaction and patient outcomes
• Compassionate, kind, and open-minded
• Teamwork experience
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
• Ability to work independently and exercise sound judgment in interactions with providers, payors, patients, and their families
• Ability to communicate and effectively interact with people across cultures, ranges of ability, genders, ethnicities, and races
• Effective oral and written communication skills
• Able to care for patients in-home, in-clinic, and remotely
• Bilingual/Bicultural (English and Spanish)

Physical Demands

While performing the duties of this job, the employee is required to sit for prolonged periods of time, stand, walk, talk, hear, and reach with hands and arms. Hand eye coordination is necessary to operate computers and other office equipment; must be able to operate a motor vehicle. When representing Suvida Healthcare at external events, the High-Risk Guia is also required to stand for prolonged periods of time, kneel, crouch, bend and lift, and able to move up to 30 pounds. The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.