Patient Outreach Specialist

Patient Outreach Specialist

At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families. Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors.

Celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service-centered, and more compassionate healthcare family and Employer of Choice! Will you join us Suvidanos, to help achieve our Higher Purpose?

We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve.

Our Culture & Core Beliefs

• Earn Trust
• Building Relationships
• Creating Joy
• Doing Right
• Improving Every Day
• Moving Forward

What You'll Do

Position Summary

The Patient Outreach Specialist (POS) is focused on engaging patients who have struggled to establish a relationship with their healthcare provider at Suvida and/or who have recently been discharged from an acute care setting. The POS will work alongside a multidisciplinary team to encourage patients to take an active role in their health by facilitating their engagement with Suvida, where they can access the tools necessary to make healthy lifestyle choices and adopt lifelong healthy behaviors. This position will be primarily field-based and focused on conducting home visits to unengaged patients who (a) Suvida has been unable to establish a relationship with or (b) have recently been discharged from the acute care. This role will conduct described home visits alongside a second POS and will work closely with center-based teams throughout Houston to engage hard to reach patients and educate them on the value Suvida provides. This is a non-traditional, highly flexible role requiring availability beyond standard business hours, including evenings and weekends, to effectively engage underserved populations.

Essential Responsibilities consist of but not all inclusive:

• Conduct in-home outreach visits to assigned patients to establish relationships, educate on Suvida's model, and schedule initial appointments.
• Engage patients recently discharged from acute care settings to support safe transitions and continuity of care.
• Collaborate with patients, families, caregivers, providers, and community partners to address barriers to care.
• Partner with clinical and case management teams on transitions of care (TOC), including coordination and referrals to post-acute services.
• Facilitate clear, collaborative communication across multidisciplinary teams to ensure coordinated, patient-centered care.
• Utilize knowledge of healthcare regulations, payer programs (Medicare/Medicaid), and community resources to support patient needs.
• Document all patient interactions accurately and timely within Airtable and the electronic medical record (EMR), including in-home, telephonic, and digital engagements.
• Support organizational and departmental performance goals aligned with value-based care outcomes.
• Serve as a mentor, resource, and preceptor to less experienced staff as appropriate.
• Maintain up-to-date knowledge of public assistance programs, benefits, and community-based resources.
• Assist with daily route planning and field logistics to maximize visit efficiency across assigned Houston centers.
• Work to schedule patients for their first PCP appointment during or immediately following the home visit, supporting program conversion goals.
• Perform additional duties as assigned by leadership.

What You'll Bring - Education Requirements

• High School Diploma or equivalent required
• Bachelor's Degree preferred
• Community Health Worker (CHW) certification preferred
• Active ACLS or BLS certification (or willing to obtain on within 7 days of start)

What You'll Bring - Experience Requirements

• 3–5 years of experience in a healthcare or community-based setting (or equivalent experience.)
• Experience working with senior or geriatric populations preferred.
• Proficiency with EMRs, mobile technology, and Microsoft Office Suite.
• Strong knowledge of Medicare, Medicaid, and community resource navigation.
• Ability to work independently while fostering strong interdisciplinary collaboration.
• Excellent organizational, time management, and communication skills.
• Demonstrated ability to engage diverse populations with cultural humility.
• Current and valid state issued driver's license in good standing.
• Applicant must have a minimum age of 25.
• Clean Driving Record (MVP) in past 7 years.
• Clean Criminal Background.
• Experience in Value-based care operations preferred.
• Considerable knowledge of geography of the business area and the location of roads and streets preferred.
• Comfortable working independently.
• Ability and willingness to work evenings and weekends as required by the role.
• Bilingual/Bicultural (English and Spanish required.)

Physical Demands

While performing the duties of this job, the employee is required to sit for prolonged periods of time, stand, walk, talk, hear, and reach with hands and arms. Hand eye coordination is necessary to operate computers and other office equipment; must be able to operate a motor vehicle. When representing Suvida Healthcare at external events, this role may also be required to stand for prolonged periods of time, kneel, crouch, bend and lift, and able to move up to 30 pounds. The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.