Community Health Partner

Job Description:

About the Role

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

• HS Diploma

• Unrestricted Driver’s License and vehicle for daily use

• At least 1-2 years of experience in community care or care coordination experience required

• Medical Clearance - evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation from vaccination if necessary

• Proof of COVID Vaccination - proof of receipt of a primary COVID vaccination series, or have an approved medical or religious accommodation from vaccination if necessary

•  Profficiency using technology to support members with and without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)

• Ability to learn and use scheduling platforms to ensure accurate appointment scheduling and management

• Ability to learn and 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