Job Description:

About the Role

Responsibilities

Engagement

• Receive members from engagement and care teams

• Describe program expectations (e.g., length) and goals to members

Assess/Intake

• Complete assessment and screening instruments (including for behavioral health, home safety and social needs) following protocols

  • Collaborate with psychiatrist, RN and Behavioral Health Specialist (BHS) as needed

Case Review and Care Planning

• Partner with the BHS and Psych APC to develop members’ care plans

• Support members in achieving their care plan goals

  • Work with members to create goals in care plans and coach to completion

Case conference prep with BHS

• Active participant, with the ability to present key and vital information during case conferences and lead discussion as needed

• Participate in regular Advanced Behavioral Health program huddles

Follow-up

• Weekly check-ins with members to follow-up on care coordination needs (benefits, social needs, external care) and care plan progress

• Frequent touchpoints and tight coordination with external providers and community based organizations

• Work with RN and pharmacies to coordinate in-home medication administrations

• Collaborate with BHS and Psych APC to determine need for escalation of member care

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

• Meet with members in the community (home, short-term nursing facility shelter, hospital) as needed, including as an extender of the care team for non-clinical needs

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

• Works in collaboration with: Behavioral Health Specialist, Psych Advanced Practice Clinician, Psychiatrist, Care Team Ops, Pharmacist

Requirements for the Role

• High School Diploma

• Bachelors’ degree preferred

• Unrestricted Driver’s License and Vehicle for daily use require

• Experience working with individuals with behavioral health conditions (e.g.,substance use disorders and serious mental illness) preferred

• 1+ years of Behavioral Health experience

• Medical Clearance - evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation from vaccination if necessary

• Proof of COVID Vaccination - proof of receipt of a primary COVID vaccination series, or have an approved medical or religious accommodation from vaccination if necessary

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.