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Job Description:

This role will require onsite work Monday - Friday 8:30AM-5:00PM (No nights, weekends or holidays!)

About the Role:

The Advance Practice Provider serves as a practice-based provider, supporting members with scheduled appointments, walk-ins and urgent or emergent visits across multiple modalities (Face to Face or virtually; in a hub, community or home setting). The Advance Practice Provider provides comprehensive care management, chronic disease management, urgent home-based and community-based primary care visits, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision of palliative care. They will also perform episodic urgent medical/behavioral health visits and/or telephone calls for members on your panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization. The role works collaboratively with an interdisciplinary team of clinical and non-clinical members to develop member care plans and to support members throughout their care journey. The Pod Provider also assists with the development and enhancement of clinical programs, initiatives, processes, and policies.

Responsibilities:

• You will work in a radically different model of healthcare

• Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners

• Co-manage a panel of members to improve their health holistically through longitudinal primary care, care management, and care coordination and be available via phone, during business at our hubs, or for member home-visiting

• As a full-time employee, you should aim to spend at least 30 hours of your time on Direct Patient Care (visits) in order to comply with weekly appointment goals. This should be adjusted based on member needs.

• Provide comprehensive care management, chronic disease management, urgent home-based and community-based primary care visits, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision of palliative care.

• Perform episodic urgent medical/behavioral health visits and/or telephone calls for members on your panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization

• Conduct home visits as needed, including scheduled and unscheduled urgent member needs

• Perform post-discharge visits for your panel within 48 hours of discharge from either an acute care facility or skilled nursing facility to decrease risk of readmission; perform detailed medication reconciliation, and assure that appropriate long term services are in place

• Assess cases presented to you by your Care team and utilizing your clinical competencies, prioritize member needs

• Interface with specialists, hospitals, and community based organizations to facilitate collaboration in service of our members, and promote shared decision making

• Monitor and address clinical quality gaps in care

• Utilize our custom-built care facilitation platform, Commons, and the market’s EMR to collect data, document member interactions in the field, organize information, track tasks, and communicate with your team, members, and community resources

• Assist management and leadership with the development, refinement, and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects

• Attend daily team huddles and weekly case conferences to advise on physical health needs and establish health goals as part of member’s Member Action Plan (MAP)

Requirements for the Role:

• You are a Board-Certified (or Board-Eligible within one year of employment) Nurse Practitioner or Physician’s Assistant with an unrestricted license to practice in the state in which you are seeking employment with Cityblock

• ANCC or AANP certification for Nurse Practitioners

• Active DEA Controlled Substance Registration or eligible for application

• Certified in Basic Life Support for Healthcare Providers

• Maintenance of professional credentialing and CME standards

• Work a full-time 40 hour week, Monday-Friday

• You have experience providing clinical services to individuals with both chronic medical and behavioral health conditions, and have interest in serving complex, vulnerable, and disabled populations

• Proven skills, knowledge base, and judgment necessary for independent clinical decision-making

• You are an adaptable organized, efficient, independent self-starter and problem-solver, a leader, a strategic thinker, and a mentor, who is excited about the big picture of whole community health

• You are excited about how technology can support your work and help drive the ongoing evaluation toward new and better care

• Your work may take you outside of normal business hours as urgent member needs arise

• Have proficient experience using and navigating an EMR

• You have an unrestricted driver’s license and vehicle for daily use

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.