Responsibilities
- Build trusting, ongoing relationships with patients, families, caregivers, and medical/behavioral health providers.
- Engage high‑risk or targeted patient populations using bi-directional communication to address health questions, concerns, and care needs.
- Identify and assess medical, behavioral, social, emotional, and financial needs to support whole‑person care.
- Support patients in understanding and following care plans, health goals, and preventive care needs, including education and motivational interviewing.
- Conduct non‑clinical assessments, surveys, and interventions to help patients navigate medical, behavioral, and social systems.
- Assist with referrals, transportation, appointment scheduling, and linkage to specialty care or community‑based resources (CBOs).
- Utilize knowledge of referral processes, prior authorizations, gaps in care, SDOH factors, and community programs to improve patient outcomes.
- Escalate medical issues appropriately to RN Care Managers, Social Workers, PCP offices, or Guidehealth leadership.
- Accurately and promptly document all interactions, assessments, and interventions in the electronic health record (EHR) and Guidehealth documentation systems.
- Demonstrate comfort using various EHR platforms (e.g., Epic, Athena, Cerner), analytics tools, and Microsoft Office.
- Manage referrals, track tasks, complete reconciliations, and maintain detailed records according to Guidehealth policies.
- Meet assigned Key Performance Indicators (KPIs) tied to patient engagement, health outcomes, and reduction of medical spend.
- Participate in Guidehealth meetings, training sessions, and quality‑of‑care initiatives.
- Follow all HIPAA, PHI security, and Guidehealth privacy policies.
- Maintain professionalism, compassion, empathy, cultural competence, and sound judgment in all interactions.
Requirements
- Build trusting, ongoing relationships with patients, families, caregivers, and medical/behavioral health providers.
- Engage high‑risk or targeted patient populations using bi-directional communication to address health questions, concerns, and care needs.
- Identify and assess medical, behavioral, social, emotional, and financial needs to support whole‑person care.
- Support patients in understanding and following care plans, health goals, and preventive care needs, including education and motivational interviewing.
- Conduct non‑clinical assessments, surveys, and interventions to help patients navigate medical, behavioral, and social systems.
- Assist with referrals, transportation, appointment scheduling, and linkage to specialty care or community‑based resources (CBOs).
- Utilize knowledge of referral processes, prior authorizations, gaps in care, SDOH factors, and community programs to improve patient outcomes.
- Escalate medical issues appropriately to RN Care Managers, Social Workers, PCP offices, or Guidehealth leadership.
- Accurately and promptly document all interactions, assessments, and interventions in the electronic health record (EHR) and Guidehealth documentation systems.
- Demonstrate comfort using various EHR platforms (e.g., Epic, Athena, Cerner), analytics tools, and Microsoft Office.
- Manage referrals, track tasks, complete reconciliations, and maintain detailed records according to Guidehealth policies.
- Meet assigned Key Performance Indicators (KPIs) tied to patient engagement, health outcomes, and reduction of medical spend.
- Participate in Guidehealth meetings, training sessions, and quality‑of‑care initiatives.
- Follow all HIPAA, PHI security, and Guidehealth privacy policies.
- Maintain professionalism, compassion, empathy, cultural competence, and sound judgment in all interactions.
Work Arrangement
Remote (Worldwide)
