• Working primarily remotely, Healthguides will be working with the patient’s medical practice staff and Guidehealth’s Case Management team, to manage a targeted population of patients. • Functioning independently and being a highly collaborative team member as an extension of medical practice. • Assisting the patient in achieving better health outcomes by addressing their questions and concerns, connecting them with the medical practice, partnering in implementing high-impact care plans and closing care gaps, escalating medical issues, and navigating them to the right resources including assisting with referrals to specialty care and community-based organizations (CBOs). • Accurately documenting patients’ medical history and medical issues in the electronic health record (EHR). • Understanding the referral and prior authorization process. • Continuously building a trusting, professional, working relationship with assigned medical practices and within the Guidehealth organization. • Implementing and meeting assigned Key Performance Indicators to produce a positive patient health outcome, while decreasing medical spend. • Utilize effective communication modalities (calls, texts, portals, emails) to engage and schedule high-risk patients. • Appropriately escalating medical issues to the Health Guide Registered Nurse, Primary Care Physician Medical practice or Guidehealth leadership. • Following all security policies and procedures in order to protect all PHI (Protected Health Information) under Guidehealth’s custodianship as well as Guidehealth Intellectual Properties. • Position may require compensated travel as needed (10-15%) to clinical sites in the Atlanta, GA area for patient and provider engagement and conducting retinal eye exams with paid training provided.