Field-Based Community Health Advocate

Cityblock Health; Raleigh (NC); On-site; USD 37,000 - 48,000; Full time

Benefits offered by this job

Health insurance

Life insurance

Retirement benefits

Equity program

Paid time off

Job summary

Cityblock Health is seeking Community Health Partners to support integrated social care for members with complex health needs. You will collaborate with RN Care Managers, manage a caseload, and help address social determinants of health in community settings.

You will conduct behavioral health screenings, develop care plans, and coordinate referrals to community resources to close gaps in care, while documenting interactions for the care team and partners.

Qualifications

• 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 elevate clinical concerns.
• Communication: High quality written, verbal and presentation communication.
• Has previous experience with documentation.

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 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.

Skills

Care coordination

Community health

Health promotion

Communication

Documentation

Job description

Cityblock Health is seeking Community Health Partners to support integrated social care for members with complex health needs. You will collaborate with RN Care Managers, manage a caseload, and help address social determinants of health in community settings.

You will conduct behavioral health screenings, develop care plans, and coordinate referrals to community resources to close gaps in care, while documenting interactions for the care team and partners.