Behavioral Health Community Guide

Overview

Location:

Kansas City, MO 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 30 mi community service area

Reports To:

Care Team Manager

About Reema Health:
Reema Health believes that a personalized, community-based approach to care makes it easier for anyone to access what they need to improve their lives. We aim to reduce barriers caused by complex systems and believe building a relationship with a real person who listens, meets members where they are, and understands community resources can connect members to health care. We use technology to support human connection and engagement, serving as a lifeline for those navigating life’s challenges.

This role is for an experienced and self-motivated Behavioral Health Community Guide who has worked with individuals living with serious mental illness and substance use disorder and understands the needs of this community. The Behavioral Health Community Guide will work with the multidisciplinary care team to plan and coordinate services for members.

The Behavioral Health Community Guide is a key part of a startup focused on transforming how behavioral health care and social care collaborate. The role involves building genuine, positive relationships with a diverse range of members and supporting their health and wellbeing through an integrated technology platform used to call and text members, schedule visits, document interactions, and communicate with the clinical team.

The guide will manage the full lifecycle of a caseload, including initial outreach, ongoing engagement toward wellbeing goals, and completion of the care plan. They will work within an integrated model of care partnering with clinicians to provide holistic support. A primary strength is excellent verbal and written communication, relationship-building, problem solving, and comfort with the evolving startup environment.

This position requires significant time in the field, directly interacting with members who may have experienced trauma and face barriers related to mental, physical, and chemical health. It is suited for individuals confident in engaging with many people.

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 information 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:

• Create and manage a caseload of 60 - 100 members through cold outreach 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 guide them through enrolling in behavioral and mental health services.
• Establish trusting relationships with members and provide meaningful, quality support with timely follow-through to achieve wellbeing goals.
• Collaborate with clinicians by helping patients connect to care, joining clinical visits as appropriate, and following up on social needs.
• Coordinate referrals and support appointment scheduling and attendance with behavioral health, primary care, and other service types for members.
• Understand overall goals for the month; independently organize and prioritize workload to achieve monthly goals and outcomes.
• Actively listen, empathize, and respect the vulnerability of members; maintain professional boundaries and confidentiality, seeking consultation with the multidisciplinary team as needed.
• Visit members in person as appropriate (home, community, hospital, or other treatment settings) to build trust and maintain connection with Reema’s clinical services.
• Utilize text, phone, email and in-person interactions to match communication with each member’s preference and situation.
• Identify and connect members…