Community Health Advocate, Complex Care

About the role:

At Accompany Health, we’re building the best model of care for patients with serious medical and social needs-people who are too often let down by the traditional healthcare system. As a Complex Care Health Advocate, you’re on the front lines of our mission to help patients stay safe, stable, and thriving at home.

You’ll visit patients in their homes to facilitate video visits, collect vital signs, complete social and clinical screenings,and support our interdisciplinary team-including primary care, nursing, behavioral health, pharmacy, and urgent care providers. You’ll help patients manage their conditions, follow through on care plans, and take proactive steps to avoid unnecessary hospitalizations-all while building trusted relationships that are the foundation of long-term health. Receive enhanced training to manage patients with complex physical and behavioral health.

Area Covered:

This role will be covering an area encompassing Howell, MI & Pontiac, MI

Responsibilities will include:

• Complex Clinical Care
• 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, and/or conduct virtual visits with primary care or behavioral health clinicians or nursing, ensuring smooth technology use and readiness
• Document, monitor and report patient status: Independently capture vitals, track changes in condition, and communicate early warning signs to the care team
• 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 complex care coordination: Support patient accountability with medication changes, referrals, appointment scheduling, testing, and home health services
• Reinforce care plans: Coach patients and hold them accountable to self-management goals, including medication adherence, diet, mobility, and mental health
• Prevent avoidable hospital use: Recognize red flags and escalate promptly to nursing or urgent care partners to enable timely intervention
• Deliver and support in-home services: Deliver supplies, equipment, or medications following AH internal procedures and educate patients on proper use
• Health Coaching: Support patients with setting goals, tracking behaviors and supporting through barriers that prevent patients from hitting their goals
• 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
• Complex Behavioral Health
• Build trusted relationships: Engage proactively with patients experiencing SMI and SUD to build trust, reduce barriers to care, and support ongoing engagement
• 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)
• Coordinate access to BH and SUD services: Guide patients through referrals and access to detox, rehab, methadone programs, and community mental health services
• Coordinate pharmacy care: Arrange medication delivery, verify access to MOUD (e.g., Suboxone), and schedule LAI and alcohol use disorder medication appointments (e.g., Vivitrol)
• Manage BH team operations: Schedule appointments for psychiatrists, Psych APCs, and BHCs, and ensure seamless coordination with the internal behavioral health team
• Navigate community resources: Learn and maintain deep knowledge of local SMI/SUD resources while fostering relationships with community partners
• Support transitions of care: Coordinate with inpatient psychiatry and medical hospital teams, including conducting in-hospital care coordination visits
• Reinforce behavioral health care plans: Support patients in managing medications, maintaining sobriety, reducing harm, and staying out of the hospital
• Maintain a comprehensive resource directory: Update and organize local and national resources (mental health, SUD, housing, transportation, financial assistance, food access, medication discounts, support groups)
• 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
• Exhibits calm even in ambiguous or rapidly changing situations
• 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
• 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 direct patient care or home-based role such as Medical Assistant, Health Coach, Community Health Worker, EMT or similar
• Comfortable in managing emergency situations, as they arise, to ensure the safety and health of the patient
• Comfort caring for medically and socially complex adults-those with multiple chronic conditions, functional limitations, or frequent hospital use
• Strong interpersonal and communication skills, with an ability to meet patients where they are
• Competence in basic clinical tasks (vital signs, observation, infection control) and technology (smart devices, video platforms, EHR documentation)
• 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
• Ability to cover the geography as assigned

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