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.

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 Medical Director of Care Transitions is a leadership position that reports to the Head of Acute and Episodic Care.

This role will drive the national cost and quality performance of market  activities related to care coordination of the Cityblock population including acute, post-acute, community, and home care services while assuring communication and connection to longitudinal care teams.

The role will provide operational oversight, coaching, and mentoring to local market leadership and care  teams to improve member safety and experience by avoiding unnecessary procedures, hospital  admissions, and readmissions, and to alternatively utilize appropriate community-based medical, social, and behavioral services.  

This role is largely a remote position, with no more than 40% travel time. 

Requirements for the Role:

• Provides clinical oversight in the development of transitional care policies, procedures, and programs and their implementation across all Cityblock markets, adjusting to each market’s different needs  
• Oversees the development of Transitional Care goals, priorities, and metrics.
• E.g., ED/Hospital admissions metrics, readmission rates, length of stay, acute care costs
• Develops programs with other clinical leaders to improve efficiency of delivery of care services and communication across all members of the Care Transitions and longitudinal care teams 
• Works in close partnership with markets to provide guidance and support to local leadership in developing close partnerships with local community healthcare partners that provide services for Cityblock patients (Home Health services, Behavioral Health Services, Hospice services and others) that have proven to have exceptional  health care outcomes, exceptional patient satisfaction metrics and lower costs
• Works with local markets to promote improved relationships with Hospital leadership (CEO/CMO, ED and Hospitalist  Medical Directors and Director of Case Management) with the goal of safely transitioning the  patient back to the Primary Care Physician and Community Care Team. 
• Facilitates the communication between the ED physician and the Primary Care Physician to increase ED diversion back to community care
• Facilitate the communication with hospitalist to discuss and coordinate clinical plan of care, reduce wasteful diagnostic interventions and inpatient consultations, reduce length of stay, and ensure post-discharge follow up compliance
• Works in close partnership with the Finance leaders and Managed care plans to:
• Develop Utilization Management Oversight programs/interventions; determine  appropriateness of levels of care and utilization of services
• Support accurate budget forecasts based on highest cost HCC diagnoses driving ED visits, hospitalizations and utilization of resources
• Provides oversight for areas of responsibility and guidance/mentoring for market leaders on the interventions mentioned above. Determines (in collaboration with other leaders) the need for and allocation of human resources to achieve the Transitional Care Organizational goals
• Collaborates with other leaders to develop programs which address quality improvement, streamlined processes, and overall exceptional team performance

How We Define Success:

• Deliver acute care for a complex population of members in a collaborative, interdisciplinary team model 
• Effective supervision and leadership of clinical care within interdisciplinary team, ensuring highest quality of care
• Ensure members receive appropriate care for acute and chronic diseases
• Collaborate effectively with other Cityblock providers and longitudinal care teams
• Timely documentation and loop closure
• Net promoter score (bedside manner)
• Active participation in virtual urgent care model development, redesign, and innovation

Nice to Have, But Not Required:

• Experience providing virtual care services, either over chat, video or phone 
• Experience with home-based care models
• Cross-licenced in multiple states (highest priority for NY, MA, NC)
• Comfort using new technologies
• Multilingual 
• Experience performing bedside ultrasounds

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.