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About Us: #communityhealth
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, 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:
The Cityblock Community Behavioral Health Care Manager supports integrated primary and acute medical care, behavioral health and social care, advancing equity in access and outcome. By working with members, the multidisciplinary team, and external partners, we proactively work to ensure all our members receive the best possible care.
The Behavioral Health Care Manager (BHCM) provides proactive care management and care coordination to individuals with primary behavioral health conditions in the clinic, virtually, at home and in the community. The BHCM works as a part of an integrated care team including the member, their supports, the Cityblock care team--including primary care providers, community health partners (CHPs), nurses, Behavioral Health (BH) Therapists, psychiatrists and other community resources. The BHCM manages transitions of care and ensures appropriate follow-up (as required by NCQA and contractually), including for discharges from psychiatric hospitalizations, behavioral health related emergency visits, and medical admissions due, in part, to behavioral health reasons. The BHCM triages members referred to the BH Team to ensure each member receives and/or is connected with the appropriate level of services. The BHCM identifies risk factors, conducts assessments, identifies the member’s stages of change, and uses motivational approaches to develop shared action plans. The BHCM strives to earn our members’ trust. BHCMs are accountable for helping members utilize resources effectively and efficiently and ensuring members have achieved designated health outcomes. In addition, many of these members have medical and social needs that the BHCM will need to consult and coordinate with the care team.
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 team of Community Health Partners.
- Be the accountable care manager for designated members with significant behavioral health needs.
- Ensure key population health metrics are achieved.
- Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET. Your work may take you outside of normal business hours as urgent member needs arise. In the future there may be an on-call pool that leads to rare off-hour calls from colleagues.
- Refer to Cityblock Behavioral Health Specialists and make referrals to external community therapists, psychiatrists, and other high quality behavioral health resources as needed.
- Follow up with members closely to ensure they follow through with care recommendations, eliminating barriers to engagement with their internal and external providers.
- Be an expert in measuring stages of change. Understand member readiness to make changes, appreciating barriers to change. Anticipate relapse from substance use disorders and intervene accordingly.
- Follow members closely while they are inpatient, in detox/withdrawal mgmt programs, in residential programs and/or intensive day programs. Liaise with both the inpatient team and the Cityblock team to ensure continuity of care.
- For transitions of care, ensure follow up and escalation plans are detailed, clear and achievable. Ensure follow up appointments are scheduled and completed by 7 and 30 day benchmarks. Closely follow members through the transition period according to CBH transition of care metrics/standards.
- Actively participate in daily team huddles and case conferences to advise, develop and document behavioral health and care management needs and goals as part of member’s Member Action Plan (MAP).
- Integrate behavioral health services with Cityblock medical and social care, including in some situations through a Collaborative Care model.
- Actively participate in planning and/or implementation of initiatives related to Behavioral Health integration and collaboration with external vendors, community-based service providers, and/or the larger Cityblock Care Team
- Be responsible for the BH quality metrics for your assigned members.
- Utilize our custom-built care facilitation platform, Commons, and the EMR to document notes, track tasks and communicate with other members of the care team.
Requirements for the Role:
- You are an LICSW, LCSW or LMHC with at least 5 years of experience in assessing, planning, and managing patient care as acquired through three years of clinical experience, including direct therapy and care management work.
- 3-5 years in care management role preferably in a health plan, ambulatory care, or community service provider managing high risk population, duals preferred, and transitions of care
- Working knowledge of Medicare and Medicaid programs and experience with regulatory compliance and reporting requirements.
- Advanced communication and interpersonal skills with all levels of internal and external customers.
- Are Tech savvy, able to talk, type, and document in the moment. Comfortable using Google Suite, Slack, and other tech platforms
- Are excited about how technology can support your work and help drive the ongoing evaluation toward new and better care
- Strong organizational and communication skills
- Extensive knowledge of Medicare and Medicaid, benefits and community resources
- Proven experience in developing and sustaining internal and external client relationships with healthcare professionals, including community service providers
- Strongly prefer
- Bilingual language skills, most prevalent need includes Spanish, Vietnamese, French Creole, Cantonese, Russian, Mandarin
- Experience with Medicaid and / or members with social needs
How We Define Success:
- Performs a variety of diverse and complex care management responsibilities, ensuring that all service needs are met through development and monitoring of an integrated action plan
- Able to conduct over 5 intake assessments weekly and over 30 care coordination activities
- Responsible for managing a panel of members with a primary behavioral health diagnosis
- Utilizes relevant behavioral health interventions to educate members, manage their care and support the development of self-management and self efficacy skills for members
- Ensures assessments are completed, initially and ongoing, reviews them and ensures that key insights are integrated into a comprehensive care plan in coordination with the interdisciplinary team
- Maintains an integrated care plan for identified needs and monitors the delivery of services for individuals with co-morbidity to improve both behavioral health and physical health outcomes and identifies the need to update goals and interventions based on member needs.
- Utilizes techniques such as motivational interviewing, harm reduction, trauma informed care principles, de-escalation techniques and other evidence-based practices to deliver member-centric care
- Identifies service delivery gaps and barriers, ensures appropriate evaluations, service planning and delivery and monitors member progress
- Partners with the provider and clinical team on the process of medication reconciliation
- Conducts disease coaching, provides education to members and is proficient in the management of multiple common comorbidities
- Works closely with other members of the care team, members’ family and caregivers, and case management staff, particularly the Department of Mental Health, in care planning
- Responsible for coordinating with the Long Term Services Support Coordinator (LTS-C) in the co management BH-designated members with LTSS needs
- Collaborates with care team in coordination of care and care planning during transitions of care Identifies service delivery gaps and barriers, ensures appropriate evaluations, service planning and delivery and monitors member progress
Nice to Have, But Not Required:
- 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!
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.