Healthguide - Community Resource

WHO IS GUIDEHEALTH?  Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.   As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business—ensuring we continue to grow and you continue to thrive as a high-performing, mission-driven team. Join us as we put healthcare on a better path!!   The Community Resource Guide is a key member of Guidehealth’s care delivery model, serving as a bridge between patients, primary care physicians, specialty providers, community resources, and the Guidehealth clinical team. This role blends patient navigation, care coordination, community resource connection, and foundational health and well-being support to help patients overcome barriers to care and progress toward improved health outcomes. The Community Resource Guide engages patients remotely and, at times, in person to help them understand their health needs, navigate medical, behavioral health, substance use, and social systems, close gaps in care, and access appropriate resources. This role supports whole-person health by building trusting relationships, addressing social drivers of health, coordinating services, and escalating emerging needs through established workflows. The Community Resource Guide contributes to Guidehealth’s value-based care performance by supporting quality outcomes, reducing avoidable utilization, improving patient engagement, supporting risk adjustment accuracy, and influencing total cost of care through proactive, compassionate, and efficient care navigation. WHAT YOU'LL BE DOING Building trusting, ongoing relationships with patients, families, caregivers, medical providers, behavioral health providers, and community partners. Engaging high-risk or targeted patient populations through bi-directional communication to address health questions, concerns, barriers, and care needs. Identifying and assessing medical, behavioral health, substance use, social, emotional, and financial needs to support whole-person care. Supporting patients in understanding and following care plans, health goals, preventive care needs, and recommended follow-up. Providing patient education and motivational interviewing support within role scope to encourage engagement, adherence, and behavior change. Conducting non-clinical assessments, surveys, and interventions to help patients navigate medical, behavioral health, substance use, and social systems. Using multiple communication methods, including phone, text, video visits, patient portals, email, and AI-enabled engagement tools, to engage and support patients. Recognizing and escalating changes in patient condition, adherence risks, social needs, or emerging clinical concerns using structured workflows. Applying foundational clinical and care navigation insight to identify high-risk trends and prioritize interventions. Operating within a value-based care model, supporting population health strategies, quality performance, and efficient resource utilization across assigned patient panels. Strengthening connections between patients and their healthcare providers by addressing barriers, facilitating communication, and coordinating follow-up. Assisting patients with referrals, transportation resources, appointment scheduling, specialty care access, and linkage to community-based organizations. Using knowledge of referral processes, prior authorizations, gaps in care, social drivers of health, and community programs to support improved patient outcomes. Escalating medical, behavioral health, social, or care coordination concerns appropriately to RN Care Managers, Social Workers, primary care offices, Guidehealth leadership, or other designated resources. Supporting achievement of quality measures, including eCQM, HEDIS®, preventive care, chronic condition management, and commercial payer measures, by coordinating preventive screenings and timely follow-up care. Supporting risk adjustment and accurate capture of patient conditions through structured assessments and documentation. Assisting in closing care gaps tied to quality incentives, reimbursement models, and value-based care outcomes. Identifying opportunities to reduce avoidable emergency department visits, hospitalizations, and readmissions through proactive outreach and intervention. Accurately and promptly documenting all interactions, assessments, interventions, referrals, escalations, and outcomes in the electronic health record and Guidehealth documentation systems. Using various EHR platforms, such as Epic, Athena, Cerner, or other systems, along with analytics tools, Microsoft Office, and Guidehealth applications. Managing referrals, tracking tasks, completing reconciliations, and maintaining detailed records according to Guidehealth policies and procedures. Supporting technology-enabled workflows, including AI-enabled outreach to identified populations. Maintaining accurate documentation to support care coordination, quality performance, risk adjustment, and compliance requirements. Working independently while col