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High Risk Guia

Job Details

Aldine - Houston, TX


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, Suvidas 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
Primary Responsibilities

  • Actively engage a panel of assigned patients within Suvida Healthcare
  • Onboard patients to the Suvida model and their medical/social care visits
  • Function as a patient advocate by attending patient appointments when requested/needed
  • Document relevant information about the patients health and healthcare experience, and perform health risk and social needs assessments
  • Collaborate with a multidisciplinary team to care for a population of patients and monitor and track whether patients are up to date on preventive measures
  • Provide patient education on acute and chronic disease management
  • Provide guidance to patients and families
  • Establish healing relationships with patients and families
  • Learn to employ confidence-promoting techniques in patient communication and develop patient self-efficacy to better manage health
  • Communicate with patients in-person and by phone, video conference, and text messaging
  • Collaborate with other members of the multidisciplinary care team including but not limited to the Guia manager, Transitions of Care manager, Medicaid case managers, and medical assistants
  • Coach patients using an action-planning model based on motivational interviewing techniques
  • Assist with the coordination of care across the continuum, such as: scheduling appointments with providers, coordinating referrals, and sharing or transferring information with the patients internal and external care team
  • Participate 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
  • Track patient enrollment and progression through care programs
  • Other duties as assigned by the Guia Manager


Education Requirements

  • High school graduate, GED

Experience Requirements 

  • Experience in a customer service environment
  • Some clinical experience is a plus, such as LVN, EMT, MA, CNA
  • Able to articulate Suvida Healthcare mission in relation to patient satisfaction and patient outcomes
  • Interpersonal communication skills and great people-person with exceptional listening abilities
  • Compassionate, kind, and open-minded
  • Teamwork experience
  • Proficient with computers, mobile devices, medical devices, and Microsoft Office Suite
  • Written communication skills
  • 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
  • Effective oral and written communication skills
  • Able to care for patients in-home, in-clinic, and remotely
  • Bilingual/Bicultural (English and Spanish) Preferred
  • Experienced assessing and addressing social needs or SDoH Preferred
  • Community Health Worker (CHW) Certification Preferred

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 Low-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.