Community Health Worker

Who We Are

At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well‑being of an underserved community and their families. Our multi‑disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare‑eligible Hispanic seniors.

We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well‑being of the seniors we serve.

Our Culture & Core Beliefs

• Earn Trust
• Building Relationships
• Creating Joy
• Doing Right
• Improving Every Day
• Moving Forward

• 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.

• 4‑5 years of experience working in a 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…