Community Health Partner at Cityblock Health

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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, one block at a time. 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.
 
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. We will get started in new markets, each with their own operating structure and care teams, and continue to grow in the communities where we are working already. 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 members in the East New York & Crown Heights, Brooklyn communities 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
  • You will be on a large team of Community Health Partners, expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members. 
  • Cooperatively care manage a population living with complex medical and behavioral health needs. 
  • Steer a care team, constantly communicating with other team members and members around their needs and health goals. 
  • 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. 
  • Go above and beyond to connect with patients 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, patients, and family members.. This platform is being built for a mobile workforce, and you will have the opportunity provide feedback to the product development team and co-design a platform that fits team needs, and, over time, become part of a super-user group to assist in onboarding and supporting others.

Requirements for the Role:

  • You have experience with patient navigation, management, or any kind of direct service provision.
  • You have a passion for working within the community you are a part of, or have been a part of in the past.
  • Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with the occasional Saturday shift. Your work may take you outside of normal business hours as urgent member needs arise. 
  • You excel at empathy and human interactions, and want to improve the health of individuals and whole communities.
  • 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:

  • Member Panel - Increase your caseload after joining Cityblock as you add members to your panel. 
  • CBH engagement - Successfully consent new members by meeting enrollment targets within 90 days and 9 months of attribution. 
  • Health Plan engagement - Through outreach, engage members by phone or unscheduled visits with the goal of engaging 55% within 6 months of attribution and 85% within 12 months
  • Initial Assessment - Complete initial assessments 75% of members within 45 days of consent
  • Active MAPs - Ensure active Member Action Plans for 75% of members within 60 days of consent.
  • Advanced Care Planning - Document advance care planning in Commons for 95% of members within one year of consent
  • Transitions of Care - Partner with Care Team to ensure that expectations and targets for transitions of care are met. After discharge from inpatient, emergency or observation in medical facilities, this may include Cityblock clinician visits, connections with others on the Care Team, or medication reconciliation within specified time frames.
  • Member Communications - Answer the majority of phone calls from members that are received during business hours.
  • Member Tends - Percent of enrolled members who receive acuity-appropriate interactions with the Cityblock team 
  • Net Promoter Score - Support high engagement with Cityblock (measured using NPS) among members

Nice to Have, But Not Required:

  • 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

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 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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Location

We're in DUMBO, where toy elephants parachute from rooftops and Thursdays are for live music. Plus, Sweetgreen, Brooklyn Roasting Company, & Equinox!
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