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 following protocols, and collaborating with RN Care Manager to determine need for member placement in a different program.
• Participate in case reviews and care planning, working with the RN Care Manager to develop members' care plans, incorporating quality opportunities, and supporting members in achieving their care plan goals.
• Bring preliminary goals and identified resources to members to address social and care coordination needs, focusing on goals of the members, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs.
• Attend case conferences, follow up with members to follow-up on care coordination needs (benefits, social needs, external care) and care plan progress, and provide routine non-clinical education on preventative care topics to members.
• 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 are needed, and supporting loop closure on internal referrals (e.g., Behavioral Health Specialist, Pharmacists, Mobile Integrated Care team).
• Utilize 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

• Bachelor’s degree required.

Skills

• Telehealth and virtual care coordination.
• Community health and social services coordination.
• Behavioral health support.
• Healthcare policy and advocacy.
• Collaborative problem-solving.

Benefits

• Health insurance.
• Life insurance.
• Retirement benefits.
• Equity program participation.
• Paid time off, including vacation and sick leave.

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.