Pod Provider (APC)

Job Description:

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:

• Conduct comprehensive clinical intake visits. Provide longitudinal direct primary care or wrap-around care with focus on chronic condition management and preventative care. 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. 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. Prescribe 1st and 2nd line medications for depression, anxiety, alcohol use disorders and opioid use disorders.
• Remain up to date on evidence-based care for complex patients in primary care: (adult only, pediatric in certain markets). 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).
• 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. Collaborate on a panel of members to provide clinical input, including health maintenance, chronic disease management and co-occurring psychiatric disorder support.

Work Experience:

• 3+ experience

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location.

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 team, and every 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. We will go above and beyond to connect with 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.