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

About the Role:

• 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 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 need.
• 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 several home visits in a given day, 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 9am to 5pm ET with possibility of occasional evenings and weekends
• 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
• Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy), assessment and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, depression.
• 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
• You have an unrestricted driver’s license and vehicle for daily use
• Have proficient experience using and navigating an EMR
  
  
  

  How We Define Success:

  • Manage a complex population of members in collaboration with an interdisciplinary team

  • Ensure members on your panel receive appropriate care for acute and chronic diseases, including following ED visits and acute admissions

  • Decrease unnecessary hospitalizations, emergency room visits, and unnecessary speciality referrals

  • Complete comprehensive provider visits with new Cityblock-assigned members. Identify core member needs the Cityblock team will address to improve health outcomes and decrease total cost of care

  • Meet evolving monthly and quarterly targets for visits with Cityblock members, in both clinic and home setting

  • Engage in target setting for new clinical initiatives and managing those targets

  
  

  Nice to Have, But Not Required:

  • You have experience caring for members in a low-income community or in a community health setting

  • You have experience with Family Medicine, and are comfortable with pediatrics.

  • You have experience working collaboratively with an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff

  • Multilingual

• What We’d Like From You:
• A resume and/or LinkedIn profile
• 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.
  
  
• We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.