Job Description

The Community Health Manager is required to provide social-health assessment, coaching and case management for residents with complex social and health needs, in collaboration with social care providers and the RHSO Community Care Team, including nurses, medical social workers and doctors.
He/she is required to lead and supervise Health Coaches in partnership with community agencies in preventive health, and to address issues of social determinants of health, to be effective in client outcomes.
He/she shall coordinate case/group/ multi-disciplinary discussions, and community development activities and programmes to improve population health.
Job Responsibilities

• Perform health and social assessment on patients/ residents with complex social and health needs.
• Perform and evaluate the effectiveness of social prescription.
• Develop personalised health plan to support resident with stable chronic disease.
• Evaluate progress of the health plan with appropriate theories and framework
• Escalate care gaps / issues to community nurses.
• Advise and guide Community Health Coaches on residents with complex social and health needs.
• Coordinate referral to primary care providers (GP/NUP) to ensure continuity of primary care for residents.
• Assist residents in navigating the health system and enhancing care coordination.
• Remove barriers to health by coordinating and referring residents to housing, financial, social, food and mental health support services.
• Manage resident with complex health and social needs and escalate according to escalation matrix where appropriate.
• Participate and lead in multi-disciplinary discussion with community agencies and / or health care team.
• Conduct and lead community needs assessment and identify health-related issues affecting the community.
• Collaborate with community agencies to pool resources to support health of the community.
• Develop, implement, and evaluate health related events and activities.
• Support the implementation of standards of care, organisation health policies, procedures, and programmes.
• Lead and guide Community Health Coaches/Managers in designated zone to achieve effective work processes and outcomes.
• Develop preceptors to induct and guide new staff, and enhance competencies of the team
• Develop training programs that promote skill enhancement for Community Health Coaches/Managers.
• Build a culture of lifelong learning.

• A degree relevant to health or social sciences is preferred.
• Knowledge and experience in case management is an added advantage.
• Work experience in health or social service sector is an advantage.
• Abilities to integrate health and social knowledge in case management would be critical.
• Able to communicate, network and collaborate with stakeholders.
• Able to work independently and collaboratively within a team.
• Strong organizational, coordination, and interpersonal skills
• Proficient in computer skills and Microsoft Office
• Able to converse in local dialects is preferred.