Behavioral Health Community Guide - Community Health

Behavioral Health Community Guide

Location: Detroit, MI metro area

FLSA Status: Exempt

Job Status: Full Time

Work Model: Hybrid

Work Schedule: Monday–Friday with occasional evenings and/or weekends

Vehicle Required: Yes

Amount of Travel Required: 25-50% within a 25mi community service area

Reports To: Care Team Manager

At Reema Health, we believe that a personalized, community-based approach to care makes it easier for anyone to access the things they need to make their lives better. We know that life’s challenges often exist because the systems built to help are a burden to navigate. We believe building a relationship with a real person — someone who listens, meets members where they are, and understands the community’s resources — can ease those burdens and effectively connect members to health care. Reema believes that using technology to support human connection and engagement can be a lifeline for those most struggling to navigate life’s challenges. Our mission-driven and member-focused company is seeking an experienced and self-motivated Community Guide who has worked with individuals living with serious mental illness and substance use disorder, and understands the unique needs of this community. In this role, the Community Guide will be working with the multidisciplinary care team to plan and coordinate services for members.

This energetic and adaptable Community Guide is an integral part of Reema, a start-up working to transform how behavioral health care and social care work together. The Community Guide works to build genuine, positive relationships with a diverse range of members and seeks to improve the member’s health and wellbeing. Their work is completed daily through an integrated technology platform to call and text members, schedule community visits and clinical appointments, as well as document all interactions and communicate with the clinical team. The Community Guide will be responsible for the full lifecycle of their caseload, including initial outreach to engage members in services, ongoing work with members to achieve their wellbeing goals through connection to health care and community resources, and completion of the care plan. The Community Guide will work as part of an integrated model of healthcare where they partner directly with clinical therapists and prescribers to provide holistic support for members. A primary strength of the Community Guide should be excellent verbal and written communication, building strong meaningful relationships, problem solving, and a comfortability in navigating the ambiguous nature of a constantly growing and evolving startup.

This position requires significant time in the field, directly interacting with members. This role is most suitable for someone who is confident in interacting directly with many people, many of whom have experienced trauma and face barriers because of their mental, physical and chemical health.

Outreach and engagement into care:

• Engage and work alongside clients from diverse ethnic backgrounds, focusing on those with: severe and persistent mental illness, substance use disorders and complex medical conditions.
• Reach out to members and share about Reema Health to enroll them in our care model.

Provide high quality and meaningful support to members to achieve improved health and wellbeing outcomes:

• Through cold outreach create and manage a caseload of 80 - 100 members and provide coverage for other Community Guides during periods of absence or increased workload.
• Assess member needs and support systems, including social determinants of health, to help create a patient-centered care plan.
• Assess member behavior and mental health needs and actively participate in guiding them through the process of enrolling in behavioral and mental health services. 
• Establish trusting relationships with members, reliably provide meaningful and quality support, and follow-through in a timely and appropriate manner to achieve their wellbeing goals.
• Collaborate with our clinicians by helping patients connect to care, joining clinical visits as appropriate, following up on social needs.
• Coordinate referrals and support appointment scheduling and attendance with behavioral health, primary care, and other provide types for members.
• Understand overall goals for the month. Independently organize and prioritize workload with effective time and task management skills to achieve monthly goals and outcomes.
• Actively listen, empathize, and appreciate the vulnerability of members willing to share their challenges. Community Guides will maintain professional boundaries and confidentiality, seeking consultation and support with complex member situations from the multidisciplinary team.
• Visit members in person as appropriate. This may be in the member’s home, community, the hospital or other treatment setting to build trust and maintain connection with Reema’s clinical services.
• Utilize text, phone, email and face-to-face interactions appropriately to match your communication approach with each members’ preference and situation.
• Effectively identify and connect members to community and health resources to support member needs. This may include transporting members and accompanying them to access other services.  Establish relationships with resources to support Reema’s members as needed.
• Prepare members for services ending by keeping self-sufficiency and independence top of mind.

Complete accurate and thorough documentation and record keeping in a timely manner:

• Utilize the Reema App to thoroughly document all work with members in a timely fashion, including keeping a care plan updated. 
• Understand and comply with confidentiality of protected health information and HIPAA.
• Support member records to be thorough and accurate in both Reema’s technology and our EHR.

Provide positive representation of Reema:

• Work independently and collaboratively in a fast-paced startup environment. See frequent change as an opportunity rather than a barrier. 
• Serve diverse members in your community with dignity and respect, as well as build relationships with community resources and customers. 
• Partner with Reemates across the multidisciplinary team and the company to offer your perspective and learn from others.

Job responsibilities to grow and change as business necessitates.

Education, Experience and Skills:

• Bachelor’s degree in Social Work, Human Services, Psychology, Health Sciences or other related fields. Years of related experience and subsequent expertise can be substituted for years of completed education towards a bachelor's degree

• 3 or more years of direct experience with population or community to be served and knowledge of community
• Driven to work with individuals who have significant mental and chemical health needs and believe that recovery is possible
• Demonstrated experience with crisis planning, case management, boundaries and personal safety in community work
• Proficiencies in critical thinking, time management, strategizing, and multitasking
• Strong propensity towards building and maintaining relationships through initiating conversations and creating connections
• Ability to develop, adapt, and execute outreach and care plans
• Proficiency with mobile devices (smartphone and tablet) required; Apple iOS experience (iPhone and iPad) preferred
• Fluency in Google Workspace applications (Gmail, Google Docs, Sheets, Slides, Drive, and Meet) required for day-to-day communication, documentation, and collaboration
• Comfortable working in web-based platforms and apps across mobile and desktop browsers, with the ability to adapt quickly to new digital tools
• Demonstrated ability to independently troubleshoot technical issues, including connectivity, app functionality, and device performance, and escalate appropriately when needed

Qualifications & Position Requirements:

• 18 years of age or older
• Qualified applicants must have flexible and reliable access to transportation, a valid Driver's License, Vehicle Insurance, and a satisfactory driving record
• Offers are contingent upon passing a pre-employment drug screening and background check
• Comply with federal, state and local regulations regarding patient confidentiality HIPAA
• Use technology-based tools and systems daily
• Lift and carry up to 25 pounds occasionally

Benefits: 

• Competitive Salary
• Medical, Dental, and Vision Insurance
• HSA and FSA Options
• 401(k) Retirement Savings Plan
• Employee Assistance Program
• Technology Stipend
• Mileage Reimbursement
• Accrued Paid Time Off
• Paid Family and Medical Leave

As an equal opportunity employer, Reema Health is committed to a diverse workforce. Employment decisions regarding recruitment and selection will be made without discrimination based on race, color, religion, national origin, gender, age, sexual orientation, physical or mental disability, genetic information or characteristic, gender identity and expression, veteran status, or other non-job-related characteristics or other prohibited grounds specified in applicable federal, state and local laws. 

Reema Health has reviewed this job description to ensure that essential functions and basic responsibilities have been included. It is intended to provide guidelines for job expectations and assess the prospective employee and/or current employees ability to perform the position described. It is not intended to be interpreted as an exhaustive list of all functions, responsibilities, skills, and abilities for this role. Additional functions and requirements may be assigned by supervisors as deemed appropriate.