• Build trusting, ongoing relationships with patients, families, caregivers, and medical/behavioral health providers. • Engage high-risk or targeted patient populations using bi-directional communication to address health questions, concerns, and care needs. • Identify and assess medical, behavioral, social, emotional, and financial needs to support whole-person care. • Support patients in understanding and following care plans, health goals, and preventive care needs, including education and motivational interviewing. • Conduct non-clinical assessments, surveys, and interventions to help patients navigate medical, behavioral, and social systems. • Strengthen the connection between patients and their healthcare providers by addressing barriers, facilitating communication, and coordinating follow-up. • Assist with referrals, transportation, appointment scheduling, and linkage to specialty care or community-based resources (CBOs). • Utilize knowledge of referral processes, prior authorizations, gaps in care, SDOH factors, and community programs to improve patient outcomes. • Escalate medical issues appropriately to RN Care Managers, Social Workers, PCP offices, or Guidehealth leadership. • Accurately and promptly document all interactions, assessments, and interventions in the electronic health record (EHR) and Guidehealth documentation systems. • Demonstrate comfort using various EHR platforms (e.g., Epic, Athena, Cerner), analytics tools, and Microsoft Office. • Manage referrals, track tasks, complete reconciliations, and maintain detailed records according to Guidehealth policies. • Work independently while collaborating closely with Guidehealth case management teams and medical practice staff. • Meet assigned Key Performance Indicators (KPIs) tied to patient engagement, health outcomes, and reduction of medical spend. • Participate in Guidehealth meetings, training sessions, and quality-of-care initiatives. • Follow all HIPAA, PHI security, and Guidehealth privacy policies. Maintain professionalism, compassion, empathy, cultural competence, and sound judgment in all interactions.