We named our company firsthand because we believe that lived, or “firsthand,” experience is invaluable for gaining trust and building meaningful relationships. While we are listing this role externally as Peer Recovery Specialist—a widely recognized term—internally we refer to this important role as firsthand Guide (fG), or a Core Guide. In our peer-led model, fGs play a critical role in outreach and engagement, supporting individuals living with SMI to achieve and maintain both behavioral and physical wellness. Trust is at the heart of everything we do, and fGs are uniquely empowered to connect with people who have disengaged from—or never accessed—the services and supports that can improve their quality of life. This role carries the expertise of a Peer Recovery Specialist, but with our distinctive approach and mission woven into every interaction.

The Core Guide partners closely with other members of the firsthand Care Team to drive whole health wellness. This includes working closely with clinicians and other support team members to ensure individuals get the support they need. fGs act as the point of contact for individuals, helping them schedule appointments, advocate for their needs and set and achieve goals.

As a Core Guide, you will:

• Conduct community outreach to individuals with SMI in homes, community locations, and care settings like shelters, hospitals, and emergency departments
• Support individuals health needs by scheduling appointments, taking vitals, ensuring clinical visits are attended and completed, and assisting with telehealth access
• Build trust and relationships by addressing immediate needs and empowering individuals to identify and pursue personal recovery goals
• Serve as the primary point-of-contact, using advanced engagement techniques to facilitate ongoing connection and engagement in supportive services
• Help  address social determinants of health, facilitating access to benefits, resources, and transportation
• Assist with care coordination, advocating for individual goals, accompanying individuals to appointments, and addressing post-discharge needs
• Provide timely and thorough documentation of encounters and participate in case reviews and team collaboration
• Perform initial and ongoing telephonic outreach
• Participate in ongoing training and professional development
• Understand that as firsthand learns and grows, your role will constantly evolve. This job description represents many key elements of this role, but they are subject to change

Core Guides should have:

• Empathy, compassion, and approachability 
• Excellent listening, communication, and interpersonal skills
• Personal knowledge of recovery
• Patience, persistence and a desire to help individuals experiencing SMI and/or SUD on their wellness journey
• Comfort working collaboratively within multidisciplinary team
• Basic proficiency with smartphone and computer technology 
• Openness to receiving feedback and a commitment to professional growth

The required experience you bring to this role includes:

Lived experience with SMI and/or SUD

• State Peer Recovery certification, or eligibility and willingness to obtain certification within six (6) months of employment
• Valid driver’s license in good standing, with the ability to operate a vehicle (company vehicle may be provided) and eligibility to drive under the company’s insurance policy
• Demonstrated proficiency with technical tools like email, messaging services, and apps
• Two (2) years demonstrated recovery time from a mental health and/or substance abuse disorder at the date of application
• Team members will complete a paid training period prior to serving individuals and must pass assessments to move forward.
• Ability to work Monday - Friday 8:30 am - 4:30 pm 

Bonus points for:

• Experience with direct in-person outreach and engagement for individuals with SMI and SUD
• Expertise in recovery education and coaching
• Understanding of whole health and trauma-informed approaches to peer support
• Familiarity with local community resources, behavioral health systems, and the criminal justice system (e.g., mental health and drug courts)
• Eagerness to expand knowledge about a broad range of health conditions
• Interest in gaining a Community Health Worker (CHW) Credential after hire, or already holds one

Reports To: Director of Clinical Services  

About Luminary Hospice: 

At Luminary Hospice, we are a mission-driven organization that empowers our team members to shape our culture in order to allow them to provide the highest quality support to patients and families throughout their entire end-of-life journey. 

Our mission is to deliver personalized care that radiates compassion and preserves dignity for all that we are honored to serve on their end-of-life journey. We are centered on caring for the whole person – with expert medical care, pain management as well as emotional and spiritual support along with resources, information, and emotional support for families and caregivers.  

About the role:  

The PRN Masters of Social Worker contracted or employed through the organization is responsible for the implementation of standards of care for medical social work services and for adherence to all conditions in the Service or Employment Agreement.  

Job Responsibilities: 

1. Assesses the psychosocial status of patients and families/caregivers related to the patient's terminal illness and environment and communicates findings to the registered nurse and other members of the interdisciplinary group.  Provides an assessment in the patient's identified residence and assistance when this is not safe, and another plan is required. 
2. Carries out social evaluations, including family dynamics, caregiver abilities, communication patterns, high risks for suicide, neglect, or abuse, and plans intervention based on evaluation findings.  Counsels patient and family/caregivers as needed in relationship to stress, and other identified coping difficulties. Provides crisis intervention when necessary. 
3. Assesses for, and educates interdisciplinary groups, on any special needs related to the culture of the patient and family. Includes communication, role of family, space, and any special traditions or taboos. 
4. Maintains clinical records on all patients referred to social work. 
5. Educates patients and families on, and assists in, the preparation of advanced directives. 
6. Provides information and referral services for organization patients and families/caregivers regarding practical and environmental needs. 
7. Provides information to patients and families/caregivers and community agencies. 
8. Serves as liaison between patients and families/caregivers and community agencies. 
9. Maintains collaborative relationships with organization personnel to support patient care. 
10. Maintains and develops contracts with public and private agencies as resources for patients and personnel. 
11. Participates in the development of the individualized plan of care, involving the patient and family, and attends regularly scheduled interdisciplinary group meetings, assisting the team in recognizing the effects of the psychosocial stresses on the symptoms of the terminal illness. 
12. Assists physician and other team members in understanding significant social and emotional factors related to health problems and death/dying issues. 
13. Actively participates in quality assessment performance improvement teams and activities. 
14. Assists family and patient in planning for funeral arrangements, and financial, legal, and health care decision responsibilities. 
15. Other duties as delegated by the Clinical Supervisor.  

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job.  The incumbents may be requested to perform job-related tasks other than those stated in this description.  

Job Qualifications: 

1. A graduate of a master’s program in social work (MSW) accredited by the Council on Social Work Education  

OR  

1. A graduate of a bachelor’s program in social work accredited by the Council on Social Work Education.  Meets personnel qualifications stated in §418.114(b)(3). 
2. Minimum of one (1) years of experience in health care, hospice experience preferred. Understands hospice philosophy, and issues of death/dying. 
3. Experience in hospice care preferred. 
4. Demonstrates good verbal and written communication, and organization skills. 
5. Possesses and maintains current CPR Certification. 
6. Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.  

Physical Demands: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

While performing the duties of this job, the employee is frequently required to sit or stand. The employee must occasionally lift and/or move up to 50 pounds. 

Equal Employment Opportunity: 

Luminary Hospice is an equal opportunity employer and is committed to creating a diverse and inclusive workplace. We do not discriminate against any applicant or employee based on race, color, religion, gender, gender identity or expression, sexual orientation, national origin, age, disability, veteran status, genetic information, or any other characteristic protected by federal, state, or local laws. We are committed to providing a work environment free from discrimination and harassment, where all individuals are treated with respect and dignity. All employment decisions at Luminary Hospice are based on business needs, job requirements, and individual qualifications. 

Compensation and Benefits: 

PRN roles are not eligible for benefits.

What You’ll Do  

The role of the Community Health Worker (CHW) is to create connections between diverse, underserved, and vulnerable populations to health and social service systems. Building trust and promoting encouragement are two of this role’s key objectives. This role assists the patient in accessing community services for their specific needs. The Community Health Worker also supports medical providers and the management team by creating community outreach programs and activities. These outreach programs are designed to promote, maintain, and improve the health of the patients and their family they serve. This position reports to Clinical Leader.  

The Day to Day 

• Serves as a liaison between multiple service providers and assists with enrollment in services and community resources by delivering culturally competent care. 
• Completes applications for resources, paperwork for provider visits, and additional administrative support activities. 
• Follows up and tracks referrals and outcomes for pharmacy, durable medical equipment (DME), and home care. 
• Assists with finding and scheduling transportation, advocates for members/patients, supports clinical staff, administers health screenings, and coordinates care (including identifying and accessing resources and overcoming barriers).  
• Builds and maintains current resource inventories for service area across multiple states. 
• Identifies situations calling for mandatory reporting and carry out mandatory reporting requirements by state requirements. 
• Provides in-person patient care which may include standing, sitting, walking, pushing, pulling, and lifting.

Minimum Qualifications 

• 2+ years combined of related education, experience, or certification. 
• Community Health Worker Certification is required for positions located or serving in the following states: AR, AZ, CO, CT, FL, IN, KS, KY, MA, MD, MO, NC, NM, OH, OR, PA, RI, SC, SD, TX, UT, VA. 
• Efficient and reliable transportation, including an active driver’s license, allowing for the ability to travel across an assigned region to meet patient needs. Locations may include offices, clinics, and patient homes. 
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms.

Preferred Qualifications 

• Certified CHW, CHES, certified nurse aid, or licensed medical assistant. 
• Experience working in a multi-cultural setting. 
• Experience working for a Managed Care or Medicaid plan. 
• Experience with kidney patients. 
• Experience with translation lines and services.  
• Basic computer skills. 

About You 

• Good communication skills. 
• Good organizational skills. 
• Strong critical thinking and problem-solving skills. 
• Extensive knowledge about community and available resources. 
• Embodies Strive’s core values: Care, Excellence, Tenacity, Innovation, and Fun. 

Hourly Range: $24.28 - $27.88