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:

Required
• 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
Preferred
• 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

28 - 33 USD