Peer Support Specialist

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

📋 Description

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

• Engage high-risk or targeted patient populations through effective bidirectional communication.

• Identify and evaluate the medical, behavioral health, substance use, social, emotional, and financial needs of patients.

• Assist patients in understanding and adhering to care plans, health goals, preventive care, and follow-up recommendations.

• Provide patient education and motivational interviewing support within the scope of the role.

• Conduct non-clinical assessments, surveys, and interventions.

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

• Recognize and escalate any changes in patient condition, adherence risks, social needs, or emerging clinical concerns.

• Prioritize interventions based on foundational clinical knowledge and care-navigation insight.

• Support population health strategies, quality performance, and optimal resource utilization.

• Address barriers, facilitate communication among providers, and coordinate follow-up care.

• Assist with referrals, transportation resources, appointment scheduling, specialty care access, and community organization linkage.

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

• Promote eCQM, HEDIS®, preventive care, chronic condition management, and measures for commercial payers.

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

• Close care gaps linked to quality incentives, reimbursement models, and value-based care outcomes.

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

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

• Utilize EHR platforms, analytics tools, Microsoft Office, and Guidehealth applications.

• Manage referrals, track tasks, perform reconciliations, and keep detailed records.

• Support AI-enabled outreach workflows.

• Collaborate with care management teams, practice staff, behavioral health partners, community partners, and internal teams.

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

• Meet KPIs related to engagement, retention, quality performance, total cost of care, and timely care coordination.

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

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

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

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

• Aid in formulating best practices for documentation, outreach, resource navigation, and care coordination.

• Perform additional duties as assigned.

⛳️ Requirements

• A 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 those having complex medical, behavioral health, social, or financial needs.

• Proficient in using EHR systems or comparable documentation platforms.

• Proven ability to work efficiently in a remote setting.

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

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

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

• Ability to manage multiple tasks, utilize time effectively, and work independently.

• Familiarity with motivational interviewing, behavior change principles, patient education, or care navigation techniques.

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

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

• Ability to maintain confidentiality and comply with HIPAA, PHI security, and Guidehealth privacy policies.

• Community Health Worker certification or equivalent community health experience, when permitted 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.

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

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

• Familiarity with Epic, Athena, Cerner, or similar EHR platforms.

• 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.

• Capability to provide an internet connection with a minimum of 100 Mbps download and 10 Mbps upload.

🏝️ Benefits

• Fully remote work arrangement.

• Necessary work equipment provided at no cost.

• Medical, Dental, and Vision plans available.

• 401(k) plan with a 3% employer match for employee contributions up to 6%.

• Life and Disability insurance offered.

• Voluntary Life insurance options available.

• Employee Assistance Program (EAP) provided.

• Paid time off plans available.

• Paid parental leave offered.

• Access to learning and development resources.

• Eligibility for comprehensive benefits for full-time employees working 30+ hours per week.