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:  

Cityblock delivers care where it works best for our members. In addition to our community-based teams, we’ve made our services even stronger for COVID-19 and beyond by adding a Community Rapid Response team and Virtual Care offerings, allowing our members to access care 24/7 via the phone, video, and text message. 

As a part of the team, you’ll go above and beyond to connect with members across all of our markets in a 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 Virtual Hub delivers integrated primary and acute medical care, behavioral health and social care, powered by relationships and designed to advance equity in access and outcome. By delivering these acute and longitudinal services in-home through a combination of digital and in-person connections, we can allow members to stay at home and out of the hospital. 

As an additional service in support of our local Hubs, we provide trusted, quick, and convenient wrap around front desk support like scheduling, consenting, initial assessments, and more.

In this role, you will provide telephonic care coordination services to members, who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. You will work from home and/or from our Contact Center where you will support a caseload of members who will rely on you as the main point of contact on their virtual care team. It is integral to our care model that we are easily accessible to our members whenever they need us, wherever they need us.

As a Community Health Partner in our Virtual Integrated Health model, you will work with a panel of members on improving their health holistically. You will assess strengths, needs, and wants across all aspects of their lives. The information you glean from your conversations will trigger the development of our MAP (Member Action Plan), and your ongoing work with the member will be to determine the member’s priorities and work on goals. You will be a member’s point person, available and accessible to assist with whatever may be needed, to troubleshoot in a crisis, or to be a listening ear. You will work alongside, and will be supported by, a care team associated with each member. 

Requirements for the Role: (these are specific to the role IE: certifications, degree, years of experience, requirements to fulfill the job duties such as technical skills)

• You have experience with patient navigation, case or care management, or any kind of direct service provision.
• You have experience managing a panel of clients or patients
• You have a passion for working within the community you are a part of, or have been a partof in the past.
• You excel at empathy and human interactions, and want to improve the health of individualsand whole communities.
• Phenomenal communicator; you approach care interactions with warmth and thoughtfulness
• You are an independent self-starter and a strategic thinker who is eager to learn, improve, and grow.
• You are excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care.

How We Define Success: 

• Follow a panel of members to coordinate all aspects of their care.
• Complete holistic assessments for members, understanding barriers, needs and creating interventions specific to member’s goals and needs. 
• Continuous outreach to support building and maintaining member panels for team
• Steer a care team, constantly communicating with other team members around member needs and desires.
• Act as a subject matter expert in community resources, and assist care team with facilitating referrals to agencies, vendors or providers.
• Assist with facilitating scheduling of appointments, records coordination, or other aspects of care coordination.
• Foster lasting and trusting relationships as the face of the team and key point-of-contact to assist members in achieving goals, identifying new needs, and coordinating care.
• Meet with members in their homes, neighborhoods, and throughout the complicated paths of the healthcare system.
• Coordinate care for members, identifying and addressing their barriers to and social influences on good health.
• Participate in interdisciplinary care team meetings, huddles and care conferences.
• Be responsible for closing assigned tasks/ interventions.
• Work collaboratively with an interdisciplinary care team of RNs, Behavioral Health Specialists, Member Outreach Specialists and medical directors to provide holistic care management services. You will appropriately refer to clinical team when needed.
• Go above and beyond to connect with members and partners 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.
• Work daily within our custom-built care facilitation platform, which will enable you to collect data, organize information, track tasks, and communicate with staff, members, and family members. This platform is built for a mobile workforce, and you will use our technology in the contact center,, provide feedback to the product development team, and, over time, become part of a super-user group to assist in onboarding and supporting others.
• Perform pre/post ER calls, ensuring members understand discharge instructions, have follow up appointments, and are aware of resources such as access to HUB/ nurse line.

Nice to Have, But Not Required: 

• A LMHC or LMSW or MFT or PhD 
• Experience working with individuals with mental health and substance use diagnoses.
• Training in motivational interviewing, behavioral activation therapy, or problem solving treatment.
• Direct familiarity with clinical settings.
• Multilingual preferred (Spanish, French Creole, etc.) 
• Lived experience with Chronic illnesses

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.  

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We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.