Affiliate Manager

• Receive members from engagement and care teams
• Describe program expectations and goals to members
• Complete assessment and screening instruments, including for behavioral health disorders, following protocols
• Collaborate with RN Care Manager to determine need for member placement in a different program
• Partner with the RN Care Manager to develop members’ care plans
• Incorporate quality opportunities in care plans
• Support members in achieving their care plan goals
• Bring preliminary goals and identified resources to members to address social and care coordination needs
• Work with members to address goals in care plans and coach to completion
• Focus on members’ goals, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs
• Participate in case conferences
• Conduct ongoing check-ins with members regarding care coordination needs and care plan progress
• Activate members around preventative care topics and goal progress
• Provide routine non-clinical education on preventative care topics
• Address and respond to member needs and delegate tasks in a timely fashion
• Meet with members in the community, including home, SNF, shelter, or hospital, as needed
• Complete screenings for emerging needs
• Refer members to the care team if clinical interventions are needed
• Support loop closure on internal referrals
• Use care facilitation, electronic health record, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate with teams, members, and community resources

Explore Community Health Partner – MD at Cityblock Health. Review requirements and application details.