Flex Community Guide - Community Health

Flex Community Guide

Location: South Carolina

FLSA Status: Exempt

Job Status: Full Time

Work Model: Hybrid

Work Schedule: Monday–Friday with occasional evenings and/or weekends

Vehicle Required: Yes

Amount of Travel Required: 10-15% within a 25 mile service area

Reports To: Assistant Director Care Team Operations

At Reema Health, we believe that a personalized, community-based approach to care makes it easier for anyone to access the things they need to make their lives better. We know that life’s challenges often exist because the systems built to help are a burden to navigate. We believe building a relationship with a real person — someone who listens, meets members where they are, and understands the community’s resources — can ease those burdens. Our mission-driven and member-focused company is seeking an experienced and self-motivated Community Guide who has worked with individuals living with health challenges and social issues, and understands the unique needs of this community.

Designed for statewide impact, the Flex Community Guide delivers exceptional member care across South Carolina without regional boundaries. This role balances independent caseload management with cross-coverage and transition support for our SC teams. This energetic and adaptable Flex Community Guide is an integral part of Reema, a start-up working to transform how health care and social care work together. While this role is fully remote and open to anyone residing within the state of South Carolina, it requires a professional who is deeply connected to their local community.

The Flex Community Guide works to build genuine, positive relationships with members in an effort to improve their health and wellbeing. Their work is completed daily through an integrated technology platform to call and text members, schedule community visits, and document all interactions. The Guide will be responsible for the full lifecycle of their caseload, including initial outreach to engage members in services, ongoing work with members to achieve their wellbeing goals through connection to health care and community resources, and graduation from the program. A primary strength of the Guide should be excellent verbal and written communication, building strong meaningful relationships, problem-solving, and comfort in navigating the ambiguous nature of a constantly growing and evolving startup.

Outreach and Engagement into Care

• Engage and work alongside clients from diverse ethnic backgrounds, focusing on those with complex social needs and chronic health conditions.
• Reach out to members via cold outreach to share about Reema Health and enroll them in our care model.
• Create and manage a localized caseload of 60 – 100 members, while providing flexible coverage for other South Carolina Community Guides during periods of absence or increased workload.

Member Support and Care Coordination

• Assess member needs and support systems, including social determinants of health, to help create a member-centered care plan.
• Establish trusting relationships with members, reliably provide meaningful and quality support, and follow through in a timely and appropriate manner to achieve their wellbeing goals.
• Coordinate referrals and support appointment scheduling and attendance with behavioral health, primary care, and other provider types for members.
• Actively listen, empathize, and appreciate the vulnerability of members willing to share their challenges. Maintain professional boundaries and confidentiality, seeking consultation and support with complex member situations from the multidisciplinary team.
• Visit members in person as appropriate. This may be in the member’s home, community, the hospital, or other treatment settings to build trust, maintain connection, and meet member’s needs.
• Utilize text, phone, email, and face-to-face interactions appropriately to match your communication approach with each member’s preference and situation.
• Effectively identify and connect members to community and health resources. This may include transporting members and accompanying them to access other services. Establish relationships with resources to support Reema’s members as needed.
• Prepare members for services ending by keeping self-sufficiency and independence top of mind.

Caseload Management and Performance

• Understand overall goals fo