Community Health Partner - MD

Cityblock Health; United States; Hybrid; USD 39,000 - 44,000; Full time

Benefits offered by this job

Health insurance

Retirement benefits

Equity program

Paid time off (vacation and sick)

Job summary

Cityblock Health in Maryland seeks Community Health Partners to support integrated social care for members with complex needs. You will work closely with RN Care Managers, visit members in the community, and help connect them to social services, coordinating care across providers and settings.

The role emphasizes non-clinical education, goal-driven care planning, and proactive follow-ups, with a focus on social determinants of health and preventative care outreach.

Qualifications

• 2+ years of care coordination or related field.
• Experience managing high-volume caseloads.
• Unrestricted driver’s license and vehicle for daily use.
• Proficiency with technology to support members via phone, text, or virtual visits.
• Ability to learn scheduling platforms and EHR care facilitation tools.

Responsibilities

• Engage with members from engagement and care teams.
• Describe program expectations and goals to members.
• Complete assessments and screenings following protocols.
• Collaborate with RN Care Manager to determine care placement needs.
• Develop and update members' care plans with RN Care Manager.
• Support members to achieve care plan goals using identified resources.
• Meet with members in the community or at various settings as needed.
• Conduct routine follow-ups on care coordination and social needs.
• Use care facilitation platforms to collect and document interactions.

Skills

Care coordination

Community health

Trauma informed care

Motivational interviewing

Technology literacy

Scheduling platforms

Electronic health records

Data collection

Problem-solving

Adaptability

Education

Bachelor's degree

Job description

Job Description

Location: MD (Prince Georges or Montgomery Counties)
Type: 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

• 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

Work Experience

• 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

Education

• Bachelors Degree

Valid Unrestricted Drivers License required

The expected salary range for this position is:
$28.00 - $32.00 Hourly

• 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.

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.

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.