Community Health Partner

4 weeks ago

nc united states Jobleads-US Full time

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.

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 a 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:
  1. HS Diploma.
  2. At least 1-2 years of experience in community care or care coordination required.
  3. Unrestricted Driver’s License and vehicle for daily use.
  4. Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.).
  5. Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management.
  6. Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation.
  7. Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner.
  8. Strong problem-solving skills - can make difficult decisions and knows when to collaborate with other team members.
  9. Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members’ care and health.
  10. Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities.
  11. 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.

Covid 19 Update - Please Read:

Cityblock requires those hired into this position to provide proof that they have received the COVID-19 vaccine. Any individuals subject to this requirement may submit for consideration a request to be exempted from the requirement (based on a valid religious or medical reason) on forms to be provided by Cityblock. Such requests will be subject to review and approval by the Company, and exemptions will be granted only if the Company can provide a reasonable accommodation in relation to the requested exemption.

About Us:

Cityblock Health is the first tech-driven provider for communities with complex needs—bringing better care to where it’s needed most, block by block. Founded in 2017 on the premise that “health is local” and based in Brooklyn, we are backed by Alphabet’s Sidewalk Labs along with some of the top healthcare investors in the country.

Our mission is to improve the health of underserved communities. Importantly, our solutions are designed specifically for Medicaid and lower-income Medicare beneficiaries, and we meet our members where they are, bringing care into the home and neighborhoods through our community-based care teams and Virtual Care offerings.

In close collaboration with community-based organizations, local providers, and leading health plans, we are reorganizing the health system to focus on what matters to our members.

Our Values:

Aim for Understanding
Be All In
Bring Your Whole Self
Lean Into Discomfort
Put Members First

About our Team:

We employ a field-based, home-based care model and are committed to meeting members where they are--in their homes, in their community, and in our Hubs.

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