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.

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+ 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

Communication Technology

• Are 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).

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

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.