Job Description:

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.

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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.

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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 escalate 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. 

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 micromanaged, using good judgment to stay on course even when conditions aren't perfect.

• Accountability: Uses data and feedback to continuously reinforce their own effectiveness and ensure high-quality, reliable execution.

Growth Agent

• Development: Takes initiative to grow skills in response to changing needs of the role or team and supports newer colleagues by sharing resources or answering questions.

• Adaptability: Challenges self to improve through change, seeing it as an opportunity to grow and maintain performance by thoughtfully focusing on outcomes and the future direction.

• Innovation: Brings forward creative solutions grounded in member needs or operational efficiency and helps test and iterate improvements.

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: 

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.