Community Health Partner (Behavioral Health)

Job Description:

Behavioral health services and care programming are available to all Cityblock members. The Behavioral Health Community Health Partner (BH CHP) will manage a member panel to support care coordination and social care for high-complexity members with acute behavioral health conditions. The role works closely with members of the behavioral health team, including the Behavioral Health Specialist and Psych specialists, along with members of the longitudinal care team.

Responsibilities:

 Engagement

• Receive members from engagement and care teams

• Describe program expectations (e.g., length) and goals to members

Assess/Intake

• Complete assessment and screening instruments (including for behavioral health, home safety and social needs) following protocols

  • Collaborate with psychiatrist, RN and Behavioral Health Specialist (BHS) as needed

Case Review and Care Planning

• Partner with the BHS and Psych APC to develop members’ care plans

• Support members in achieving their care plan goals

  • Work with members to create goals in care plans and coach to completion

• Case conference prep with BHS

• Active participant, with the ability to present key and vital information during case conferences and lead discussion as needed 

• Participate in regular Advanced Behavioral Health program huddles

Follow-up

• Weekly check-ins with members to follow-up on care coordination needs (benefits, social needs, external care) and care plan progress

• Frequent touchpoints and tight coordination with external providers and community based organizations

• Work with RN and pharmacies to coordinate in-home medication administrations

• Collaborate with BHS and Psych APC to determine need for escalation of member care

• Address and respond to member needs and delegate tasks in timely fashion

• Meet with members in the community (home, short-term nursing facility shelter, hospital) as needed, including as an extender of the care team for non-clinical needs

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 

Work Experience:

•  HS Diploma

• Experience working with individuals with behavioral health conditions (e.g.,substance use disorders and serious mental illness) preferred

• Behavioral Health experience preferred

• 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  

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 an