Community Health Worker

The Guia assists a panel of Medicare-eligible Hispanic seniors within a multidisciplinary primary care team by providing comprehensive care coordination, patient education, and support to meet preventive, chronic, and acute care needs. Responsibilities include conducting in-person/home visits, coordinating referrals and access to community resources, documenting interventions in the medical record, onboarding patients to the Suvida model, and collaborating with clinicians and care team members to address social determinants of health. The role emphasizes building trusting relationships with patients and families, promoting health literacy and self-efficacy, and navigating benefits such as SNAP, LIS, PAP, and prescription assistance. Requires 4-5 years in healthcare or related experience, strong communication skills, EMR proficiency, and bilingual English/Spanish capabilities; Bachelor's degree preferred. Capable of in-home, in-clinic, and remote care as needed; familiarity with Medicare/Medicaid programs and a commitment to culturally competent care for Hispanic seniors.