Responsibilities will include:
- Build trusted relationships: Proactively in engage with patients’ to build trust and provide support to hard to reach and highest needs patients so they stay healthier, longer, at home
- Facilitate virtual visits: Set up, support, virtually troubleshoot and/or conduct virtual visits with primary care or behavioral health clinicians, ensuring smooth technology use and readiness
- Conduct in-home assessments: Record vital signs (BP, pulse, weight, O₂ sat) and provide clear and detailed observations on home environment ,functional status and administering screenings (PHQ-9, GAD-7, PCL-5, AUDIT, DAST, CIWA, COWS)
- Support behavioral health visits: Partner with clinicians during medical and BH visits by collecting vitals and administering screenings (PHQ-9, GAD-7, PCL-5, AUDIT, DAST, CIWA, COWS)
- Navigate social needs and insurance benefits: Identify and document social needs (food, housing, transportation, safety) and navigate patients through social resources and insurance benefits
- Support care plan adherence: Reinforce education, coach on medication adherence and healthy behaviors, and track progress toward goals
- Health Coaching: Support patients with setting goals , tracking behaviors and supporting through barriers that prevent patients from hitting their goals
- Coordinate care logistics: Follow up on referrals, scheduling appointments, and tests; manage delivery or pickup of home testing kits or devices
- Deliver and support in-home services: Deliver supplies and equipment following AH internal procedures
- Document and communicate effectively: Maintain accurate EHR documentation and consistent updates to the care team
- Visit Accompaniment: Accompany patients to clinical visits for support with preventative screening and gap closures
- Performs other duties as assigned
What makes you a fit for the team:
- Eager to collaborate with a mission-driven, compassionate team that’s transforming care for those who need it most
- Driven to make a real impact—helping patients close care gaps and avoid unnecessary hospitalizations and stay healthier at home
- Thrives in a fast-paced environment and able to adapt and contribute to continuous improvement
- Comfortably manages high volumes of work, can multitask, is organized and can adapt quickly as priorities shift
- Fluent in technology and excited to incorporate new technology and systems into daily practice
- Adaptable and flexible, embracing evolving systems and technology-driven workflow enhancements
- Demonstrates strong growth mindset, including the willingness to unlearn prior workflows and embrace new approaches
- Exhibits calm even in ambiguous or rapidly changing situations
- Passionate about interdisciplinary collaboration with advanced practice clinicians, nurses, behavioral health clinicians, pharmacists, and urgent care providers
- Displays trust in the organization’s mission, values, and direction, and contributes positively to a culture of shared purpose
Desired skills and experience:
- Experience in a patient-facing role (e.g., Medical Assistant, Community Health Worker, Health Coach, EMT)
- Comfortable working in patients’ homes and communities independently, including with medically or socially complex populations
- Strong interpersonal skills—able to quickly build rapport and communicate clearly with patients and clinicians
- Basic clinical and technology proficiency (e.g., vital sign collection, using mobile apps, supporting video calls)
Valid unrestricted driver's license and access to an insured vehicle for daily use - The assigned geographic area (subject to change) may include locations requiring variable drive times; however visit and travel times will be scheduled to fit within the standard workday
- Medical Assistant (CMA) or Community Health Worker (CHW) certification, or 2+ years experience in a healthcare setting
Experience with value-based care, home-based care, or virtual primary care models - Bilingual or multilingual fluency in Spanish or Arabic is a strong plus; additional fluency in other commonly spoken U.S. languages (e.g., Chinese, French, Russian, Tagalog & Vietnamese) are also a plus