Community Health Partner - MD

Cityblock Health•MD - Remote, MD

10d•$28 - $32•Hybrid

About The Position

Community Health Partners work closely with RN Care Managers to support integrated social care coordination for members with complex social, behavioral, and physical needs. The role involves spending significant time visiting members and, at times, their caregivers by telephone, virtually, at a hub, or in the home. Community Health Partners help members navigate and connect with community-based and social services and coordinate care with internal and external providers. The role includes engaging members, completing assessments and screenings, partnering with RN Care Managers on care plans, following up on care coordination needs and progress, and addressing emerging needs. Community Health Partners also meet members in community settings as needed and use care facilitation, electronic health record, and scheduling platforms to document interactions, organize information, track tasks, and communicate with members, teams, and community resources. This is a hybrid position located in Prince George’s County, Maryland.

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 in collecting member clinical and demographic data and documenting it accurately 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 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 work beyond traditional responsibilities.
Adaptability to frequent, fast-paced changes and shifting priorities.
Bachelor’s degree.
Completion of medical clearance requirements, including evidence of immunity to MMR, Hepatitis B, and Varicella and a TB screen, or an approved medical or religious accommodation that precludes vaccination against these diseases.

Responsibilities

Receive members from engagement and care teams.
Explain program expectations, such as program length, and goals to members.
Complete assessment and screening instruments, including behavioral health disorder screenings, in accordance with protocols.
Collaborate with the RN Care Manager to determine whether a member should be placed in a different program, including a lower- or higher-intensity program.
Partner with the RN Care Manager to develop members’ care plans and incorporate quality opportunities into those plans.
Support members in achieving care plan goals by presenting preliminary goals and identified resources, addressing social and care coordination needs, and coaching members toward completion.
Focus on member goals, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs.
Participate in case conferences.
Conduct ongoing member check-ins about care coordination needs, benefits, social needs, external care, and care plan progress.
Activate members around preventive care topics and progress toward goals, and provide routine non-clinical education on preventive care.
Address and respond to member needs and delegate tasks in a timely manner.
Meet with members in community settings, including homes, skilled nursing facilities, shelters, and hospitals, as needed, to extend the care team for non-clinical needs.
Complete screenings for emerging needs and refer members to the care team when clinical interventions are needed.
Support closure of internal referrals, including 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 member interactions, organize information, track tasks, and communicate with the team, members, and community resources.