Job Description
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. 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 i
