Telephonic Community Health Partner

Cityblock Health - Charlotte, NC

Who we are:
At Cityblock Health, our mission is to radically improve the health of urban communities, block by block. We integrate services to address physical, behavioral, and social needs together, delivered at community hubs and through mobile, field-based care teams to make healthcare more accessible, supportive and goal-driven for the people who need it most.

Every aspect of the Cityblock care model is carefully designed to focus on our members, engaging and empowering them to own and improve their health through trusted relationships. Through field-based, interdisciplinary care teams, we are flexible in how we deliver care, meeting members where they are, and together developing and working longitudinally through a personalized and integrated Member Action Plan (MAP). The care team collaborates to support each member's whole health and social needs. Enabled by custom-built technology, we build capacity, deliver care and dramatically change members' opportunities and outcomes.

Partnering with community-based organizations and a well-respected commercial partner in North Carolina, and backed by the top healthcare investors in the country, we are reorganizing the health system to focus on what matters to our members—and leading the move from transactional, fee-for-service medicine towards high-value, relationship-based partnerships.

The role:
In this role, you will provide telephonic care coordination services to members, who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. You will reside in our Contact Center where you will support a caseload of members who will rely on you as the main point of contact on their virtual care team. It is integral to our care model that we are easily accessible to our members whenever they need us, wherever they need us.

As a Community Health Partner in our Tele + model, you will work with a panel of members on improving their health holistically. You will assess strengths, needs, and wants across all aspects of their lives. The information you glean from your conversations will trigger the development of our MAP (Member Action Plan), and your ongoing work with the member will be to determine the member's priorities and work on goals. You will be a member's point person, available and accessible to assist with whatever may be needed, to troubleshoot in a crisis, or to be a listening ear. You will work alongside, and will be supported by, a care team associated with each member.

You will:
  • Follow a panel of members to coordinate all aspects of their care.
  • Complete holistic assessments for members, understanding barriers, needs and creating interventions specific to member's goals and needs.
  • Continuous outreach to support building and maintaining member panels for team
  • Steer a care team, constantly communicating with other team members around member needs and desires.
  • Act as a subject matter expert in community resources, and assist care team with facilitating referrals to agencies, vendors or providers.
  • Assist with facilitating scheduling of appointments, records coordination, or other aspects of care coordination.
  • Foster lasting and trusting relationships as the face of the team and key point-of-contact to assist members in achieving goals, identifying new needs, and coordinating care.
  • Coordinate care for members, identifying and addressing their barriers to and social influences on good health.
  • Participate in interdisciplinary care team meetings, huddles and care conferences.
  • Be responsible for closing assigned tasks/ interventions.
  • Work collaboratively with an interdisciplinary care team of RNs, Behavioral Health Specialists, Member Outreach Specialists and medical directors to provide holistic care management services. You will appropriately refer to clinical team when needed.
  • Go above and beyond to connect with members and partners in a non-judgmental, respectful and empathic manner, to meet their needs, and to provide feedback to the system as a whole as we strive to do better every day.
  • Work daily within our custom-built care facilitation platform, which will enable you to collect data, organize information, track tasks, and communicate with staff, members, and family members. This platform is built for a mobile workforce, and you will use our technology in the contact center,, provide feedback to the product development team, and, over time, become part of a super-user group to assist in onboarding and supporting others.
  • Perform pre/post ER calls, ensuring members understand discharge instructions, have follow up appointments, and are aware of resources such as access to HUB/ nurse line.
You'd be a good fit if:
  • You have experience with patient navigation, case or care management, or any kind of direct service provision.
  • You have experience managing a panel of clients or patients
  • You have a passion for working within the community you are a part of, or have been a part of in the past.
  • You excel at empathy and human interactions, and want to improve the health of individuals and whole communities.
  • Phenomenal communicator; you approach care interactions with warmth and thoughtfulness
  • You are an independent self-starter and a strategic thinker who is eager to learn, improve, and grow.
  • You are excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care.
Nice to have:
  • A LMHC or LMSW or MFT or PhD
  • Experience working with individuals with mental health and substance use diagnoses.
  • Training in motivational interviewing, behavioral activation therapy, or problem solving treatment.
  • Direct familiarity with clinical settings.
  • Unrestricted North Carolina driver's license and vehicle for daily usage
  • Multilingual preferred (Spanish, French Creole, etc.)
  • Lived experience with Chronic illnesses
  • Experience within the Charlotte community
  • Experience with pediatrics
You should include these in your application:
  • A resume and/or LinkedIn profile.
  • A 1-2 paragraph response indicating why this job is compelling to you.
  • A 1 paragraph summary of a time when you thought you made a difference in someone's health.
Cityblock values diversity as a core tenet of the work we do and 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.