Community Health Partner

Cityblock Health•Winston-Salem, NC

1d•$27 - $35

About The Position

Community Health Partners (CHPs) work alongside RN Care Managers to deliver integrated social care coordination for members with complex needs (social, behavioral, and physical). CHPs spend significant time connecting with members and caregivers (telephonic, virtual, hub, or in-home), assisting them with navigation, accessing community-based and social services, and coordinating care with both internal and external providers. Multiple openings are available in Charlotte, Triad (Greensboro, Winston-Salem, Highpoint), Fayetteville, and Wake County.

Requirements

Bachelor's Degree in a health-related field
Minimum 2+ years of progressive experience in social work, care coordination, community health, health promotion, or a related field.
Demonstrated ability to manage a high-volume caseload.
Unrestricted Driver’s License and access to a reliable vehicle for daily use.
Technical proficiency in using virtual visit platforms, electronic health records (EHRs), and scheduling software for accurate documentation and communication.
Proficiency in Motivational Interviewing and Trauma-Informed Care principles.
Strong problem-solving skills with the ability to provide creative solutions to systemic challenges impacting member care and health optimization.
A growth-oriented and adaptable mentality, prepared for frequent and fast-paced changes and shifting priorities.

Responsibilities

Engage new members referred from engagement and care teams. Clearly describe Cityblock program expectations and goals to members.
Conduct comprehensive assessment and screening instruments, including for behavioral health disorders, following established protocols.
Collaborate with the RN Care Manager to determine appropriate member program placement (e.g., lower or higher intensity).
Develop members' care plans in partnership with the RN Care Manager. Incorporate quality opportunities into care plans.
Support and coach members to achieve their care plan goals, focusing on goals of the members, risk mitigation, provider engagement, and addressing social needs.
Participate in routine case conferences.
Conduct ongoing check-ins to monitor care coordination needs (benefits, social needs, external care) and care plan progress.
Provide routine non-clinical education and actively engage members in preventative care topics and goal progression.
Respond to member needs promptly, completing screenings for emerging needs and appropriately delegating tasks.
Facilitate care by meeting with members in the community (e.g., home, shelter) as an extender of the care team for non-clinical needs.
Manage all internal and external referrals, ensuring support for loop closure with internal teams (e.g., Behavioral Health Specialist, Pharmacists, Mobile Integrated Care team).
Utilize care facilitation, electronic health record, and scheduling platforms to collect data, document member interactions, track tasks, and communicate with the care team, members, and community resources.