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.
- 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 and in their community. You will go above and beyond to connect with members in the Worcester, Massachusetts community 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, leveraging expanded care teams, in-person and virtual care models, as well as a proprietary homegrown IT platform for collaborative patient assessment and management
- Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners
- As a Cityblock Clinician, you will co-manage with a panel of complex members in a value-based care environment to provide diagnosis, treatment, counseling, medication management, acute triage and follow up care
- Your work will be primarily focused on direct-patient care in the community
- Develop a strong understanding of disease management across your member panel support the panel with a population health lens
- Your work will be centered in our Hub and in the field - extending out in the surrounding neighborhood and community. You will meet people where they are, both physically and emotionally
- Your work will be scheduled and unscheduled member visits - you may perform urgent clinical assessments as needed
- You may provide clinical supervision to Advanced Practice Providers (NPs/PAs)
- Partner closely with Nurse Practitioners to co-manage, triage and assess Cityblock members’ complex needs with the goal of stabilizing active medical issues in the larger context of their overall health needs
- Identify and collaborate closely with existing outpatient behavioral health providers, primary care providers and specialists to promote shared decision making in our member’s health and successfully co-manage (WRAP) members
- You will also have the opportunity to be the Primary Provider for members without identified PCPs and work with members longitudinally to achieve their goals.
- 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
Requirements for the Role:
- You are an independent self-starter, a leader, and a strategic thinker who is excited about the big picture of whole community health, and the ongoing evaluation and iteration of our care model
- You are an MD or DO, Board Certified in Internal Medicine, Family Medicine, or Medicine-Pediatrics, Geriatrics, or Palliative Care with an unrestricted license to practice in the state in which you are employed with Cityblock
- You can work a full-time work week, Monday-Friday 9am to 5pm ET with one late evening a week. You will also participate in a Saturday Rotation and the Cityblock on-call schedule. Your work may take you outside of normal business hours as urgent member needs arise.
- You have the experience or excitement to provide direct care to underserved populations with complex needs
- You have experience working within an interdisciplinary team
- You are excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care
- You demonstrate proficiency, prior experience, and/or willingness to train in clinical 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.
- You are passionate about improving care delivery
- You are comfortable managing patients with complex medical and psychosocial needs
- You have an unrestricted driver’s license and vehicle for daily use
How We Define Success:
- Manage a complex population of members in a collaborative, interdisciplinary team model
- Ensure members on your panel receive appropriate care for acute and chronic diseases, including following ED visits and acute admissions
- Manage a primary care and co-management (WRAP) panel of members to address their long and short-term health needs, ultimately to prevent avoidable hospital and Emergency Department visits
- Meet monthly and quarterly targets for visits with Cityblock members, in both clinic and home settings
- Engage in target setting for new clinical initiatives and managing those targets
- Active participation in practice development, redesign, and innovation
Nice to Have, But Not Required:
- Experience with substance use disorder treatment
- Experience caring for individuals experiencing homelessness
- Experiencing caring for individuals with criminal justice involvement
- Experience with home-visiting/care in the field
- Experience with telemedicine
- Comfort using new technologies in healthcare
- Interest or experience in healthcare assessments and evaluation
- Interest or experience in analysis of healthcare data
What We’d Like From You:
- A resume and/or LinkedIn profile
- A short cover letter, please!