Community Health Partner

Cityblock Health; North Carolina; Presencial; USD 42.000 - 64.000; Jornada completa

Descripción de la vacante

Cityblock Health is seeking a Community Health Partner to support members with complex social, behavioral, and physical needs across NC. You will collaborate with RN Care Managers to identify barriers, develop personalized care plans, and help members access community resources in home, shelter, or hospital settings.

The role emphasizes proactive care, strong documentation, and effective communication to close quality gaps and improve health outcomes for underserved populations.

Formación

• 2+ years of progressive experience in care coordination, community health, health promotion, or a related field.
• Strong critical thinker with sound judgment who knows when to collaborate and escalate clinical concerns.
• High quality written, verbal and presentation communication. Has previous experience with documentation.
• Must have valid unrestricted driver's license.

Responsabilidades

• Collaborate with RN Care Managers to support members with complex medical and behavioral health needs.
• Manage a caseload of members, identifying and addressing social, behavioral, and environmental barriers to optimal health.
• Develop and implement care plans in partnership with members, addressing social needs and supporting members in achieving their care goals.
• Conduct self-efficacy and condition-specific assessments, including behavioral health screenings, and refer members to appropriate behavioral health programs as needed.
• Support members in closing quality gaps by assisting with provider appointments, diagnostic or lab testing, and referrals to community resources.
• Meet members in community settings (home, shelter, hospital) as needed, serving as an extension of the care team.
• Utilize care facilitation and scheduling platforms to document interactions, track tasks, and communicate effectively with members, the care team, and community partners.

Conocimientos

Care coordination

Communication

Problem solving

Documentation

Driver's license

Descripción del empleo

Job Description:

Location: NC - Market wide

About the role:

Community Health Partners (CHPs) support integrated social care for members with complex health needs (social, behavioral and physical). CHPs have an assigned panel of members and work in collaboration with an RN Care Manager to provide support for identified social determinants of health needs. They are familiar with the communities served and often bring lived experience and a strong commitment to supporting vulnerable and underserved populations.

Key Responsibilities

• Collaborate with RN Care Managers to support members with complex medical and behavioral health needs.
• Manage a caseload of members, identifying and addressing social, behavioral, and environmental barriers to optimal health.
• Develop and implement care plans in partnership with members, addressing social needs and supporting members in achieving their care goals.
• Conduct self-efficacy and condition-specific assessments, including behavioral health screenings (PHQ-9, GAD-7, AUDIT, DAST-10), and refer members to appropriate behavioral health programs as needed.
• Support members in closing quality gaps by assisting with provider appointments, diagnostic or lab testing, and referrals to community resources.
• Meet members in community settings (home, shelter, hospital) as needed, serving as an extension of the care team.
• Utilize care facilitation and scheduling platforms to document interactions, track tasks, and communicate effectively with members, the care team, and community partners.

Success Metrics

Care plans completed and updated collaboratively with members and RN Care Managers

Members demonstrate progress toward achieving social and health-related goals

Referrals and interventions effectively address social determinants of health.

Assistance with provider appointments, lab testing, and other services leads to measurable closure of identified quality gaps.

Effective communication and collaboration with RN Care Managers, interdisciplinary care team, and community partners.

Timely identification and escalation of members needing additional support or higher levels of care.

Job Requirements

• Professional Experience & Knowledge Experience: 2+ years of progressive experience in care coordination, community health, health promotion, or a related field.
• Problem Solving: Strong critical thinker with sound judgment who knows when to collaborate and escalation clinical concerns. Identifies system barriers to care and develops creative, practical solutions.
• Communication: High quality written, verbal and presentation communication. Has previous experience with documentation.
• Must have valid unrestricted drivers license.

Behavioral Competencies

• Member Advocate Mission Driven: Prioritizes tasks that have the greatest impact on service to members and mission-critical outcomes.
• Compassionate Care: Builds rapport with members and demonstrates care in interactions, anticipating and navigating emotional barriers.
• Business Acumen: Uses awareness of internal processes and healthcare systems to navigate issues more effectively.
• Team Builder Collaboration: Adapts communication style based on context, audience, or urgency and contributes to team discussions constructively even when perspectives differ.
• Team Effectiveness: Balances individual responsibilities with proactively pitching in to help others and offers constructive feedback when appropriate.
• Engaged Culture: Demonstrates humility by offering specific and timely praise or credit and acknowledging missteps with maturity.
• Results Driver Strategic Clarity: Plans and sequences work to support broader team or department outcomes, and shares updates proactively so others can stay aligned.
• Proactive Approach: Solves issues and delivers results without being