What You’ll Do
Position Summary
The Guia 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 Guia 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 Guia 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:
Responsibilities
- 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
What You’ll Bring
Knowledge, Skills, and Abilities
- 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.