The Healthguide is a key member of Guidehealth’s care delivery model, serving as a bridge between patients, their primary care physicians and specialty providers, community resources, and the Guidehealth clinical team. This role blends patient navigation with foundational clinical insight, helping patients overcome barriers to care, strengthening relationships with medical practices, coordinating resources, and supporting whole‑person health.
The Healthguide engages patients remotely and occasionally in person to help them understand their health needs, navigate medical and social systems, close gaps in care, and progress toward optimal health outcomes. In this position, you will support Guidehealth’s mission to empower patients, reduce the cost of care, and promote efficient, compassionate healthcare delivery by leading with empathy.
The Healthguide contributes directly to value-based care performance by improving quality outcomes, reducing avoidable utilization, supporting risk adjustment accuracy, and influencing total cost of care.
WHAT YOU'LL BE DOING
Patient Engagement & Navigation
- Building trusting, ongoing relationships with patients, families, caregivers, and medical/behavioral health providers.
- Engaging high‑risk or targeted patient populations using bi-directional communication to address health questions, concerns, and care needs.
- Identifying and assessing medical, behavioral, social, emotional, and financial needs to support whole‑person care.
- Supporting patients in understanding and following care plans, health goals, and preventive care needs, including education and motivational interviewing.
- Conducting non‑clinical assessments, surveys, and interventions to help patients navigate medical, behavioral, and social systems.
- Utilizing effective communication modalities (e.g., calls, texts, video visits, patient portals, emails, AI agents) to engage and support high-risk patients.
- Recognizing and escalating changes in patient condition, adherence risks, or emerging clinical concerns using structured workflows.
- Applying clinical 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.
Care Coordination & System Navigation
- Strengthening the connection between patients and their healthcare providers by addressing barriers, facilitating communication, and coordinating follow‑up.
- Assisting with referrals, transportation, appointment scheduling, and linkage to specialty care or community‑based resources (CBOs).
- Utilizing knowledge of referral processes, prior authorizations, gaps in care, SDOH factors, and community programs to improve patient outcomes.
- Escalating medical issues appropriately to RN Care Managers, Social Workers, PCP offices, or Guidehealth leadership.
- Supporting achievement of quality measures (e.g., eCQM, HEDIS, commercial payor) by coordinating preventive screenings, managing chronic conditions, and ensuring 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 and reimbursement models.
- Identifying opportunities to reduce avoidable ED visits, hospitalizations, and readmissions through proactive outreach and intervention.
Documentation & Technology
- Accurately and promptly documenting all interactions, assessments, and interventions in the electronic health record (EHR) and Guidehealth documentation systems.
- Demonstrating comfort using various EHR platforms (e.g., Epic, Athena, Cerner), analytics tools, and Microsoft Office.
- Managing referrals, track tasks, complete reconciliations, and maintain detailed records according to Guidehealth policies.
- Supporting the design and implementation of Artificial Intelligence (AI) to outreach identified populations.
Collaboration & Performance
- Working independently while collaborating closely with Guidehealth case management teams and medical practice staff.
- Meeting and exceeding Key Performance Indicators (KPIs) related to:
- Patient engagement and retention
- Quality measure performance (e.g., HEDIS, preventive care)
- Reduction in total cost of care
- Timely completion of care coordination activities
- Participate in Guidehealth meetings, training sessions, and quality‑of‑care initiatives.
Advanced Responsibilities
- Serving as a subject matter resource for workflows, documentation standards, and patient engagement strategies.
- Participating in process improvement initiatives, including workflow optimization and quality improvement projects.
- Supporting onboarding and mentoring new Healthguides.
- Providing feedback to leadership on system gaps, patient barriers, and operational opportunities.
- Assisting in the development of best practices for documentation, outreach, and care coordination.
- Other duties as assigned
Compliance & Professional Standards
- Following all HIPAA, PHI security, and Guidehealth privacy policies.
- Maintaining professionalism, compassion, empathy, cultural competence, and sound judgment in all interactions.