Community Health Partner - MD

Cityblock Health•MD - Remote, MD

9d•$28 - $32•Hybrid

About The Position

Community Health Partners (CHPs) work closely with RN Care Managers to coordinate integrated social care for members with complex social, behavioral, and physical needs. They spend significant time visiting members and, at times, their caregivers by telephone, virtually, at a hub, or in the home. CHPs help members navigate and connect with community-based and social services, and coordinate care with internal and external providers. The role includes engaging members in the program, completing assessments and screenings, collaborating on care plans, supporting members in achieving their goals, and maintaining ongoing follow-up. CHPs provide routine non-clinical education on preventive care, address emerging needs, connect members with clinical care when needed, and support closure of internal referrals. They may meet members in community settings such as homes, skilled nursing facilities, shelters, or hospitals. CHPs use care facilitation, electronic health record, and scheduling platforms to document interactions, organize information, track tasks, and communicate with members, teams, and community resources.

Requirements

At least 2 years of progressive experience in care coordination, community health, health promotion, or a related field.
Experience managing a high-volume caseload.
Unrestricted driver’s license and a vehicle for daily use.
Proficiency using technology to support members with and without in-person contact, including telephone and text etiquette and virtual visit platforms.
Ability to learn and use scheduling platforms for accurate appointment scheduling and management.
Ability to learn and use electronic health record systems and/or care facilitation platforms for accurate documentation.
Proficiency collecting member clinical and demographic data and documenting it appropriately and promptly.
Knowledge of Motivational Interviewing and Trauma Informed Care principles.
Strong problem-solving skills, sound decision-making, and judgment about when to collaborate with other team members.
Ability to develop creative solutions to healthcare-system challenges that impede members’ care and health.
Growth and learning mentality, ability to think outside the box, and willingness to go beyond traditional responsibilities.
Adaptability to frequent, fast-paced changes and shifting priorities.
Bachelor’s degree.
Completion of medical clearance requirements for member-facing roles, including evidence of immunity to MMR, Hepatitis B, and Varicella, and a TB screen, or an approved medical or religious accommodation.

Responsibilities

Receive members from engagement and care teams.
Explain program expectations, including program length, and goals to members.
Complete assessment and screening instruments, including behavioral health disorder screenings, following protocols.
Collaborate with the RN Care Manager to determine whether a member should be placed in a different-intensity program.
Partner with the RN Care Manager to develop members’ care plans and incorporate quality opportunities.
Support members in achieving care plan goals by identifying preliminary goals and resources and coaching members through completion.
Address member goals, risk mitigation, call-us-first emphasis, provider engagement, and social needs.
Participate in case conferences.
Conduct ongoing check-ins about care coordination needs, including benefits, social needs, external care, and care plan progress.
Activate members around preventive care topics and goal progress, and provide routine non-clinical preventive-care education.
Respond to member needs and delegate tasks in a timely manner.
Meet members in community settings, including homes, skilled nursing facilities, shelters, and hospitals, as needed to support non-clinical care team needs.
Screen for emerging needs and refer members to the care team when clinical interventions are needed.
Support loop closure on internal referrals, such as referrals to Behavioral Health Specialists, Pharmacists, and the Mobile Integrated Care team.
Use care facilitation, electronic health record, and scheduling platforms to collect data, document interactions, organize information, track tasks, and communicate with teams, members, and community resources.