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Job Description:

About Us:

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. You 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.

About the Role:

The Clinical Delivery team radically improves healthcare by meeting members where they are to identify and address health needs. The Pod Provider (MD/DO)role radically improves healthcare by serving as the primary care or wrap-around provider for members in Cityblock’s unique, interdisciplinary care model.

Clinical Visits

• Conduct comprehensive clinical intake visits for selected members (based on member segmentation, program empanelment and care team recommendation).

• Conduct timely follow-up for members post transition of care event, acute need or according to condition-specific needs.

• Proactively outreach to members who need follow up care.

• Provide clinical care in line with CBH protocols.

• Complete comprehensive and compliant diagnosis capture related to HCC (Hierarchical Condition Categories) and ICD-10 (International Classification of Diseases-10) Coding.

• Address contractual and company-prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure.

• Address and respond to member needs and delegate tasks in a timely fashion.

• Finish documentation according to company timelines (within 48 hours of clinical encounter) company policy.

• Weekend and on-call duties may be assigned depending on market needs.

Clinical Scope

• Prescribe 1st and 2nd line medications for depression, anxiety, alcohol use disorders and opioid use disorders.

• Continue psychiatric medications for members with stable SMI

• Remain up to date on evidence-based care for complex patients in primary care (adult only, pediatric in certain markets). Provide longitudinal direct primary care or wrap-around care with focus on chronic condition management and preventive care.

• Refer members to specialist care appropriately and according to internal CBH guidance if available.

• Support the member in achieving the goals in their care plans (physical, behavioral, and/or social health).

Case review and care planning

• Participate in case conferences with the care team, providing clinical expertise on care plan development.

• Provide guidance on highest impact clinical interventions and tasks to achieve a member’s goals.

Panel management

• Collaborate on a panel of members to provide clinical input, including preventive care, chronic disease management and co-occurring psychiatric disorder support

• Collaborate with care team to determine need for member placement in a different program (e.g., lower or higher intensity program)

Operations

• Utilize our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, vtrack tasks, and communicate with your team, members, and community resources

Leadership

• Educate, support and elevate team members’ own skills (informal coaching is a significant part of collaborative practice).

• Act as the collaborating physician for oversight of Advanced Practice Clinicians

• Complete chart reviews in compliance with CBH policy

• Guide clinical team on complex clinical cases. Be available for escalation questions at the point of care. Provide clinical consultation for care team members including information on clinical issues, support with care plans and review of clinically concerning member conditions

Requirements for the Role:

• Board certification in a major primary care in Family Medicine

• Certified in Basic Life Support for Healthcare Providers

• DEA licensure (or willingness to acquire)

• License required: Current valid license to practice medicine in the state of Florida

• Willingness to acquire licenses in other states according to CBH business needs.

• 3+ years experience Specialty Area: MD or DO in Internal Medicine, Family Medicine, Geriatrics, or similar specialty required

• Are comfortable using technology to support members (telephone and text etiquette, virtual visit platforms, scheduling platforms etc.) and to communicate with interdisciplinary team members (slack, google documents, etc).

• Documentation & Care Delivery Platforms

• Understand how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation.

• Document thorough medical, behavioral and social history with clearly communicated assessments and plans.

• Counseling Methods

• Proficient in Motivational Interviewing and Trauma informed Care principles.

• Problem solving

• Have strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members.

• Flexibility

• Have a growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities.

• Are adaptable to change and prepared for frequent, fast-paced changes and shifting priorities.

• Able to provide creative solutions to challenges within the healthcare system that are impeding members’ care and health.

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.

Covid 19 Update - Please Read:

Cityblock requires those hired into this position to provide proof that they have received the COVID-19 vaccine. Any individuals subject to this requirement may submit for consideration a request to be exempted from the requirement (based on a valid religious or medical reason) on forms to be provided by Cityblock. Such requests will be subject to review and approval by the Company, and exemptions will be granted only if the Company can provide a reasonable accommodation in relation to the requested exemption. Note that approvals for reasonable accommodations are reviewed and approved on a case-by-case basis and availability of a reasonable accommodation is not guaranteed. This vaccination requirement is based, in part, on recently established government requirements. The requirement is also based on the safety and effectiveness of the vaccine in protecting against COVID-19, and our shared responsibility for the health and safety of members, colleagues, and community.

The COVID-19 pandemic has severely impacted the health and lives of people around the world, including the vulnerable populations Cityblock serves. As a healthcare provider, Cityblock holds ourselves to the highest standards when promoting the health and safety of those who we serve. Given that the COVID-19 vaccines are one of the most powerful tools to fight this disease and save lives, Cityblock is implementing a COVID-19 booster mandate for Washington, D.C. employees under the guidance of local/state mandates.

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.