Job Description: The Cityblock Longitudinal Care Provider serves as a practice-based provider, supporting members with scheduled appointments, walk-ins and urgent or emergent visits across multiple modalities (Face to Face or virtually; in a hub setting). The Pod Provider delivers comprehensive chronic disease management (e.g. hypertension, diabetes, chronic kidney disease), evaluation of acute concerns, behavioral health condition management (i.e. depression, anxiety, alcohol and substance use disorder), and preventative care and wellness support (including sexual and reproductive health). The role works collaboratively with an interdisciplinary team of clinical and non-clinical members to develop member care plans and to support members throughout their care journey. The Pod Provider assists with the development and enhancement of clinical programs, initiatives, processes, and policies and manages the most complex patients in their market. Schedule: Monday-Friday: 9am-5:30pm Hybrid Schedule with mix of virtual and in-office (hub) Responsibilities: Clinical Visits Conducts comprehensive clinical intake visits for selected members (based on member segmentation, program empanelment and care team recommendation). Conducts timely follow-up for members post transition of care event, acute need or according to condition-specific needs. Proactively outreaches to members who need follow up care. Provides clinical care in line with CBH protocols. Completes comprehensive and compliant diagnosis capture related to HCC (Hierarchical Condition Categories) and ICD-10 (International Classification of Diseases-10) Coding. Addresses contractual and company-prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure. Addresses and respond to member needs and delegate tasks in a timely fashion. Finishes documentation according to company timelines (within 48 hours of clinical encounter) company policy. Clinical Scope Prescribes 1st and 2nd line medications for depression, anxiety, alcohol use disorders and opioid use disorders. Continues psychiatric medications for members with stable SMI Remains up to date on evidence-based care for complex patients in primary care: (adult only, pediatric in certain markets). Provides longitudinal direct primary care or wrap-around care with focus on chronic condition management and preventative care. Refers member to specialist care appropriately and according to internal CBH guidance if available. Supports the member in achieving the goals in their care plans (physical, behavioral, and/or social health). Case review and care planning Participates in case conferences with the care team, providing clinical expertise on care plan development. Provides guidance on highest impact clinical interventions and tasks to achieve a member’s goals. Panel management Collaborates on a panel of members to provide clinical input, including health maintenance, chronic disease management and co-occurring psychiatric disorder support Collaborates with care team to determine need for member placement in a different program (e.g., lower or higher intensity program) Operations Utilizes our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources Leadership Educates, supports and elevates team members’ own skills (informal coaching is a significant part of collaborative practice). Acts as the collaborating physician for oversight of Advanced Practice Clinicians Completes chart reviews in compliance with CBH policy Guides clinical team on complex clinical cases. Be available for escalation questions at the point of care. Provide clinical consultation for care team members including information on clinical issues, support with care plans and review of clinically concerning member conditions Required Work Experience: 3+ direct clinical care experience Preferred: Bilingual Spanish Education: Graduate from an accredited medical college (within the United States/Canada) or from an unaccredited medical college (outside of the United State/Canada Graduate from an accredited medical college (within the United States/Canada) or from an unaccredited medical college (outside of the United State/Canada Specialty Area: MD or DO in Internal Medicine, Family Medicine, Geriatrics, or similar specialty required Certified in Basic Life Support for Healthcare Providers DEA licensure (or willingness to acquire) Current valid license to practice medicine in the state in which you are employed with Cityblock We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $183,750.00 - $245,000.00 Annual 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. Medical Clearance (for Member-Facing Roles): You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means. 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. We 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.

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