Peer Support Specialist

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Establish and nurture trusting, ongoing relationships with patients, families, caregivers, providers, and community partners.

• Engage with high-risk or specific patient populations through two-way communication.

• Identify and evaluate medical, behavioral health, substance use, social, emotional, and financial requirements.

• Assist patients in comprehending and adhering to care plans, health objectives, preventive care, and follow-up suggestions.

• Deliver patient education and motivational interviewing support within the role's scope.

• Carry out non-clinical assessments, surveys, and interventions.

• Connect with patients via phone, text, video visits, patient portals, email, and AI-enabled tools.

• Identify and report changes in patient condition, adherence risks, social requirements, or clinical issues.

• Prioritize interventions using foundational clinical and care-navigation insights.

• Contribute to population health strategies, quality performance, and efficient resource utilization.

• Coordinate referrals, transportation resources, appointments, access to specialty care, and connections to community organizations.

• Raise concerns to RN Care Managers, Social Workers, primary care offices, leadership, or designated resources.

• Assist with eCQM, HEDIS, preventive care, chronic condition, and commercial payer quality measures.

• Aid in risk adjustment and accurate documentation of patient conditions.

• Close care gaps associated with quality incentives, reimbursement models, and value-based outcomes.

• Minimize avoidable emergency visits, hospitalizations, and readmissions through proactive outreach.

• Record interactions, assessments, interventions, referrals, escalations, and outcomes in EHR and Guidehealth systems.

• Manage referrals, track tasks, complete reconciliations, and maintain comprehensive records.

• Support AI-enabled outreach workflows.

• Collaborate with care management teams, medical practices, behavioral health partners, community partners, and internal teams.

• Participate in meetings, training sessions, quality initiatives, and process improvements.

• Achieve KPIs for engagement, retention, quality performance, total cost of care, and timely care coordination.

• Communicate patient barriers, system gaps, resource needs, and operational opportunities to leadership.

• Adhere to HIPAA, PHI security, privacy, and compliance policies.

• Act as a subject-matter expert for workflows, documentation, engagement strategies, and community resource navigation.

• Assist in onboarding, mentoring, and training new Community Resource Guides.

• Contribute to the development of best practices for documentation, outreach, resource navigation, and care coordination.

• Perform other duties as assigned.

⛳️ Requirements

• Minimum of 3 years of relevant experience in patient navigation, community resource navigation, medical assistance, health promotion, care coordination, peer support, emergency medical services, or a similar role.

• Experience working directly with patients in clinical, community-based, or non-clinical environments, preferably with patients possessing complex medical, behavioral health, social, or financial needs.

• Familiarity with EHR systems or similar documentation platforms.

• Proven ability to operate effectively in a remote setting.

• Understanding of medical terminology, primary care workflows, referral processes, and social determinants of health.

• Strong critical thinking, problem-solving, and decision-making abilities.

• Excellent verbal, written, listening, and documentation skills.

• Capacity to prioritize multiple tasks, manage time efficiently, and work independently.

• Knowledge of motivational interviewing, behavior change principles, patient education, or care navigation techniques.

• Strong customer service orientation characterized by diplomacy, tact, empathy, and professionalism.

• Ability to collaborate with patients, families, caregivers, providers, community partners, and interdisciplinary care teams.

• Commitment to maintaining confidentiality and complying with HIPAA, PHI security, and Guidehealth privacy standards.

• Community Health Worker certification or equivalent community health experience, when permissible by contract.

• Peer Support Specialist certification or related peer support experience, when permissible by contract.

• Emergency Medical Technician certification or related emergency medical services experience, when permissible by contract.

• Experience supporting value-based care, population health, care gap closure, quality performance, risk adjustment, or total cost of care initiatives.

• Familiarity with high-risk patient populations or complex medical, behavioral health, substance use, social, or financial needs.

• Experience with referral coordination, transportation resources, community-based organizations, prior authorizations, or resource navigation.

• Proficiency in using Epic, Athena, Cerner, or comparable EHR systems.

• Experience utilizing patient engagement technology, analytics tools, patient portals, Microsoft Office, or AI-enabled outreach tools.

• Bilingual skills, if aligned with the needs of the patient population.

🏝️ Benefits

• Fully remote work arrangement.

• Necessary work equipment provided at no charge.

• Medical, dental, and vision plans.

• 401(k) plan with a 3% employer match on a 6% employee contribution.

• Life and disability insurance.

• Voluntary life insurance options.

• Employee Assistance Program (EAP).

• Paid time off plans.

• Paid parental leave.

• Learning and development resources.

• Eligible full-time employees working 30 or more hours per week receive comprehensive benefits.