Field Based Guia

Who We Are

Suvida Healthcare is committed to enriching the lives of our seniors. As a Team Member, you will join a compassionate, multidisciplinary primary care program designed to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors.

We celebrate diversity and inclusivity in a workplace that values the unique needs and backgrounds of both patients and team members. We invite you to join us as we pursue our Higher Purpose.

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

Position Summary

The Community Health Worker (Field-based) engages patients who have struggled to establish a relationship with their healthcare provider at Suvida or who have recently been discharged from an acute care setting. The CHW will work alongside a multidisciplinary team to encourage patients to participate in their health, facilitating engagement with Suvida and access to tools that support healthy lifestyle choices and lifelong healthy behaviors.

This position is primarily field-based and focuses on conducting home visits to unengaged patients or those recently discharged. The role will conduct described home visits alongside a trained Sales team member and will work with center-based teams throughout Houston to engage hard-to-reach patients and educate them on Suvida’s value. This entry-level opportunity aims to make a meaningful impact in a fast-paced, value-based care environment.

Essential responsibilities include, but are not limited to:

Responsibilities

• Conduct home visits to patients assigned by their health plan to engage and educate them on the Suvida model. Help these patients schedule their first appointment at the assigned location.
• Work collaboratively with patients, family, caregivers, healthcare providers, and external partners to engage and provide support to patients recently discharged from acute care.
• Partner with the clinical and case management team on transitions of care planning and referrals to post-acute providers.
• Promote collaborative communication between all health care team members, internal multidisciplinary teams, patients, families, and significant others to ensure integrated care services are targeted, appropriate, and beneficial.
• Utilize knowledge of applicable laws, regulations, government and insurance benefits, and practice guidelines and standards of practice.
• Document all interventions in the patient medical record timely and accurately, including all elements of clinic visits, in-home, telephonic engagement, or texting.
• Support departmental goals to contribute to the success of the organization.
• Serve as preceptor, mentor, and resource to less experienced staff.
• Maintain knowledge of Medicare, Medicaid, and other program benefits to assist patients.
• Other duties as assigned by Guia Manager.

Education Requirements

• CHW certification
• Bachelor’s Degree preferred

Experience Requirements

• 4-5 years of experience working in healthcare or relevant setting.
• Expertise connecting patients and ensuring closed-loop referral with community resources and governmental agencies addressing complex social needs.
• Experience managing the needs of Senior/Geriatric populations.
• Ability to work independently and develop collaborative relations with physicians, families, patients, interdisciplinary teams, and community agencies.
• Strong organizational and time management skills with the ability to prioritize multiple tasks.
• Knowledge and ability to complete benefit applications such as SNAP, LIS, PAP, and prescription assistance.
• Effective oral and written communication skills.
• Proficiency with EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite.
• Experience using electronic…