Community Health Partner

Employment Type: Full-time

Position Overview

Community Health Partners (CHP) work closely with RN Care Managers to support integrated social care for members with complex health needs (social, behavioral, and physical). CHPs are responsible for care coordination, spending significant time visiting members (telephonic, virtual, Hub, or in-home), helping members navigate community-based and social services, and coordinating medical care with both internal Cityblock and external providers.

Responsibilities

Engagement

• Receive members from engagement and care teams.
• Describe program expectations (e.g., length) and goals to members.

Assessments/Intake

• Complete assessment and screening instruments (including for behavioral health disorders) following protocols.
• Collaborate with RN Care Manager to determine the need for member placement in a different program (e.g., lower or higher intensity program).

Case Review and Care Planning

• Partner with the RN Care Manager to develop members’ care plans.
• Incorporate quality opportunities in care plans.
• Support members in achieving their care plan goals.
• Bring preliminary goals and identified resources to members to address social and care coordination needs.
• Work with members to address goals in care plans and coach to completion.
• Focus on members’ goals, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs.
• Participate in case conferences.

Follow-up

• Ongoing check-ins with members to follow up on care coordination needs (benefits, social needs, external care) and care plan progress.
• Activate members around preventative care topics and goal progress.
• Provide routine non-clinical education on preventative care topics to members.
• Address and respond to member needs and delegate tasks in a timely fashion.
• Meet with members in the community (home, SNF, shelter, hospital) as needed, including as an extender of the care team for non-clinical needs.
• Complete screenings for emerging needs.
• Refer to the care team if clinical interventions are needed.
• Support loop closure on internal referrals (e.g., Behavioral Health Specialist, Pharmacists, Mobile Integrated Care team).

Operations

• Utilize our care facilitation, electronic health record, and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources.

Requirements for the Role

• Education: Bachelor's Degree preferred.
• Experience: At least 2 years of experience in community care or care coordination required.
• Technical Skills:
  • Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.).
  • Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management.
  • Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation.
  • Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner.
• Principles: Versed in Motivational Interviewing and Trauma Informed Care principles.
• Problem-Solving: Strong problem-solving skills; ability to make difficult decisions and know when to collaborate with other team members.
• Innovation: Able to provide creative solutions to challenges within the healthcare system that are impeding the optimization of members’ care and health.
• Mindset: Growth and learning mentality, ability to think outside the box, and go beyond traditional responsibilities.
• Adaptability: Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities.

Compensation and Benefits

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for:

• Health insurance
• Life insurance
• Retirement benefits
• Participation in the company’s equity program
• Paid time off, including vacation and sick leave.

The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location.