Job Description:

Currently mainly virtual role, but this individual will need to live be local to one of the following areas: San Antonio, TX, Dallas -Forth Worth, TX (DFW) area.

Working hours: Apx. 8AM - 5PM CST M-F (no nights, weekends or holiday)

About the Role:

The Cityblock Longitudinal Care 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 Pod Provider delivers comprehensive chronic disease management (e.g. hypertension, diabetes, chronic kidney disease), evaluation of acute concerns, behavioral health condition management (i.e. depression, anxiety, alcohol and substance use disorder), and preventative care and wellness support (including sexual and reproductive health). 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:

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.

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 preventative care.

• Refer member 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 health maintenance, 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, track 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)

• Market Medical Director, Associate Medical Director, Community Health Partner (CHP), Behavioral Health CHP, Psychiatrist, Pharmacist, RN Care Manager, Behavioral Health Specialist

Requirements for the Role:

• Education & License requirements

  • Completed an accredited NP or PA program with a national certification

  • Specialty Area requirement: Family, Geriatrics, Adult, or Primary Care

  • Board-Certified (or Board-Eligible within one year of employment)

  • Certified in Basic Life Support for Healthcare Providers

  • PA: National certification as a Physician Assistant through NCCPA.

  • Nurse Practitioner or Physician's Assistant with an unrestricted license to practice in the state in which you are employed with Cityblock.

  • DEA licensure (or willingness to acquire)

• Experience

  • 3+ years of relevant experience

• Skills required

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

  • 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.

  • Proficient in Motivational Interviewing and Trauma informed Care principles.

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

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

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

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

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.