Community Health Partner - MD - Hybrid

About the role

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

• Engage with members from engagement and care teams, describe program expectations, and goals to members.
• Absorb assessments and intake, completing 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).
• Participate in case review and care planning, working with the RN Care Manager to develop members’ care plans.
• Incorporate quality opportunities in care plans, supporting members in achieving their care plan goals, and bringing preliminary goals and identified resources to members to address social and care coordination needs.
• Follow up 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, providing routine non-clinical education on preventative care topics to members.
• Address and respond to member needs and delegate tasks in a timely fashion, meeting 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, referring members to care team if clinical interventions needed, and supporting loop closure on internal referrals (e.g., Behavioral Health Specialist, Pharmacists, Mobile Integrated Care team).
• 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

• 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.

Qualifications

Education: Bachelor's Degree

Skills

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $28.00 - $32.00 Hourly

Benefits

We value 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.

Pay

The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $28.00 - $32.00 Hourly

Schedule

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.