Community Health Partner

Job Description:

* SPANISH SPEAKING PREFERRED *

About the Role:

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, 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 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 goals of the members, 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 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

• Referral to care team if clinical interventions 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:

• High School Diploma required
• Unrestricted Driver's License and vehicle for daily use required
• At least 1-2 years of experience in community care or care coordination required
• 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            
• Versed in Motivational Interviewing and Trauma Informed Care principles
• Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members
• Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members’ care and health
• Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities
• Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities

Cityblock values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

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