Job Description:

About the Role:

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 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:

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. Note that approvals for reasonable accommodations are reviewed and approved on a case-by-case basis and availability of a reasonable accommodation is not guaranteed. This vaccination requirement is based, in part, on recently established government requirements. The requirement is also based on the safety and effectiveness of the vaccine in protecting against COVID-19, and our shared responsibility for the health and safety of members, colleagues, and community.

The COVID-19 pandemic has severely impacted the health and lives of people around the world, including the vulnerable populations Cityblock serves. As a healthcare provider, Cityblock holds ourselves to the highest standards when promoting the health and safety of those who we serve. Given that the COVID-19 vaccines are one of the most powerful tools to fight this disease and save lives, Cityblock is implementing a COVID-19 booster mandate for Washington, D.C. employees under the guidance of local/state mandates.

Medical Clearance (for Member-Facing Roles):

You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases.

We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.