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 identification and escalation of members needing additional support or higher levels of care.

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: $27.40 - $35.10 Hourly.

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.

Cityblock Health is the first tech-driven provider for communities with complex needs—bringing better care to where it’s needed most, block by block. Founded in 2017 on the premise that “health is local” and based in Brooklyn, we are backed by Alphabet’s Sidewalk Labs along with some of the top healthcare investors in the country. Our mission is to improve the health of underserved communities.

Importantly, our solutions are designed specifically for Medicaid and lower-income Medicare beneficiaries, and we meet our members where they are, bringing care into the home and neighborhoods through our community-based care teams and Virtual Care offerings. In close collaboration with community-based organizations, local providers, and leading health plans, we are reorganizing the health system to focus on what matters to our members.

Equipped with world-class, custom care delivery technology, we deliver personalized primary care, behavioral health, and social services to deliver a radically better experience of care for every member and community we serve. Over the next year, we’ll grow quickly to bring better care to many more members and their communities. To do this, we need people who, like us, believe that everyone should have good care for what matters to them, in their community.

Our work is grounded in a belief in the power of a diverse community. To close gaps in care and advance equity in the communities we serve, we have to start with making our own team diverse and inclusive. Our ways of working are characterized by creativity, collaboration, and mutual learning that comes from bringing together a community from diverse backgrounds and perspectives. We strive to ensure that every person on the Cityblock team, and every Cityblock member, feels supported and included as a part of our community.

Our Values:

• Aim for Understanding
• Be All In
• Bring Your Whole Self
• Lean Into Discomfort
• Put Members First

About our Team:

We employ a field-based, home-based care model and are committed to meeting members where they are--in their homes, in their community, and in our Hubs. We will go above and beyond to connect with Cityblock members 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.