Healthguide - Community Resource

About the role

The Community Resource Guide plays a vital role in Guide Health's approach to care delivery, acting as a crucial link among patients, primary care physicians, specialty providers, community resources, and the Guide Health clinical team. This position combines elements of patient navigation, care coordination, and community resource connection to assist patients in overcoming obstacles to care and achieving better health outcomes. The guide engages with patients both virtually and occasionally in person, helping them navigate various health systems and access necessary resources.

Key facts

What you'll do

• Establish and nurture trusting relationships with patients, families, caregivers, medical professionals, behavioral health providers, and community partners to foster effective communication and support.
• Proactively engage with high-risk patient populations through two-way communication, addressing their health inquiries, concerns, and care requirements.
• Assess and identify the medical, behavioral health, substance use, social, emotional, and financial needs of patients to promote comprehensive care.
• Assist patients in comprehending and adhering to their care plans, health objectives, preventive care requirements, and follow-up appointments.
• Provide educational resources and motivational interviewing techniques to encourage patient engagement, adherence, and positive behavior changes.
• Conduct non-clinical assessments and interventions to facilitate patients' navigation through medical, behavioral health, substance use, and social systems.
• Utilize various communication methods, including phone calls, text messages, video consultations, patient portals, emails, and AI-driven engagement tools to support patient interactions.
• Monitor and escalate any changes in patient conditions, adherence risks, social needs, or emerging clinical issues through established workflows.
• Apply foundational clinical insights to identify high-risk trends and prioritize necessary interventions for patients.
• Operate within a value-based care framework, contributing to population health strategies, quality performance, and efficient resource utilization across assigned patient panels.
• Strengthen the connection between patients and their healthcare providers by addressing barriers, facilitating communication, and ensuring proper follow-up.
• Assist patients with referrals, transportation options, appointment scheduling, access to specialty care, and connections to community-based organizations.
• Leverage knowledge of referral processes, prior authorizations, and community programs to enhance patient outcomes.
• Appropriately escalate any medical, behavioral health, social, or care coordination concerns to RN Care Managers, Social Workers, primary care offices, or Guide Health leadership.
• Support the achievement of quality measures, including eCQM, HEDIS®, preventive care, chronic condition management, and commercial payer metrics by coordinating screenings and follow-up care.
• Aid in risk adjustment and accurate documentation of patient conditions through structured assessments.
• Identify opportunities to minimize avoidable emergency department visits, hospitalizations, and readmissions through proactive outreach and intervention strategies.
• Ensure all interactions, assessments, interventions, referrals, escalations, and outcomes are documented accurately and promptly in the electronic health record and Guide Health systems.
• Utilize various EHR platforms, such as Epic, Athena, Cerner, and analytics tools, alongside Microsoft Office and Guide Health applications.
• Manage referrals, track tasks, complete reconciliations, and maintain detailed records in accordance with Guide Health policies.
• Support technology-enabled workflows, including AI-driven outreach to targeted populations.
• Maintain precise documentation to support care coordination, quality performance, risk adjustment, and compliance requirements.
• Work independently while collaborating closely with Guide Health care management teams, medical staff, behavioral health partners, community partners, and other internal teams.
• Participate in Guide Health meetings, training sessions, quality initiatives, and process improvement activities.
• Meet and exceed key performance indicators related to patient engagement, retention, quality measure performance, and timely completion of care coordination tasks.
• Communicate patient barriers, system gaps, resource needs, and operational opportunities to leadership and relevant team members.
• Uphold professionalism, empathy, cultural competence, diplomacy, and sound judgment in all interactions.
• Adhere to HIPAA, PHI security, privacy, and Guide Health compliance policies.
• Serve as a subject matter expert on workflows, documentation standards, patient engagement strategies, and community resource navigation.
• Engage in process improvement initiatives, including workflow optimization and quality improvement projects.
• Assist in onboarding, mentoring, and training new Community Resource Guides as needed.
• Provide feedback to leadership regarding system gaps, patient barriers, workflow challenges, and opportunities for operational improvement.
• Contribute to the development of best practices for documentation, outreach, community resource navigation, and care coordination.
• Perform additional duties as assigned.

Requirements

• A minimum of 3 years of relevant experience in patient navigation, community resource navigation, medical assistance, health promotion, care coordination, peer support, emergency medical services, or a related field.
• Experience working directly with patients in clinical, community-based, or non-clinical environments, particularly with those facing complex medical, behavioral health, social, or financial challenges.
• Familiarity with EHR systems or similar documentation platforms.
• Proven ability to work effectively in a structured environment.
• Understanding of medical terminology, primary care workflows, referral processes, and social determinants of health.
• Strong critical thinking, problem-solving, and decision-making capabilities.
• Excellent verbal, written, listening, and documentation skills.
• Ability to prioritize multiple tasks, manage time efficiently, and work autonomously.
• Knowledge of motivational interviewing, behavior change strategies, patient education, or care navigation techniques.
• A strong customer-service orientation with the ability to communicate with empathy, professionalism, and tact.
• Capacity to collaborate effectively with patients, families, caregivers, providers, community partners, and interdisciplinary care teams.
• Commitment to maintaining confidentiality and adhering to HIPAA, PHI security, and Guide Health privacy standards.

Nice to have

• Community Health Worker certification or equivalent community health experience, where permissible by contract.
• Peer Support Specialist certification or related peer support experience, where permissible by contract.
• Emergency Medical Technician certification or relevant experience, where permissible by contract.

Skills & tools

• Proficiency in EHR systems (Epic, Athena, Cerner) and analytics tools.
• Familiarity with Microsoft Office Suite and Guide Health applications.
• Strong communication and interpersonal skills.

Practical notes

• This is a full-time position based in Atlanta, US.
• The role requires a commitment to quality patient care and adherence to compliance standards.
• Candidates should be prepared to engage with a diverse patient population and collaborate with various stakeholders in the healthcare system.