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
Work Experience
2+ years of progressive experience in care coordination, community health, health promotion, or a related field.
Experience with High Volume Caseload
Unrestricted Driver's License and vehicle for daily use
Proficiency 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 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
Education:
Bachelors Degree
$28.00 - $32.00 Hourly
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, sexu
Benefits
Health insurancePaid time offRemote work optionsEquity / stock options
Additional Information
Job Description:
Location: Maryland (Baltimore & Montgomery County)
Work Type: Hybrid (approximately 30% in-person/community-based, equating to about 1 in-person day per week for visits with approximately 2-4 patients depending on need, and approximately 70% virtual/remote work)
Education Requirement: Bachelor's degree required
Hours: Monday - Friday, with four standard days (8:30 AM - 5:00 PM) and one scheduled extended coverage day (10:30 AM - 7:00 PM) . No nights or weekend work required.
Cityblockhealth · Remote