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.

About the Role:

The Cityblock Health Pods deliver integrated primary and acute medical care, behavioral health (including pharmacological and treatment for substance use disorders) and social care, to members with Behavioral Health conditions. 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.

In this role, you will provide care management 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 potentially work in the community, at home virtually, and/or in clinics to support a caseload of members who will rely on you as the main point of contact on their 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 Behavioral Health Community Health Partner in our Community Integrated Health model, you will work with a panel of members with high behavioral health needs to improve 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.

Key Activities:

• Outreach, engage and follow a panel of members with complex behavioral health needs to coordinate all aspects of their care. This includes phone calls, co-visits with another member of the care team, home visits and/or hospital visits
• 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
• Encourage and assist members to obtain high quality evidenced-based care, including medications such as injectable antipsychotic medications for those with schizophrenia, and medication assisted treatment for those with opioid or alcohol use disorders
• Support members to find care in the community, especially to prevent avoidable emergency room visits or hospitalizations
• Support members after a discharge from a hospital or emergency room, ensuring members understand discharge instructions, are connected to care providers, attend follow up appointments, and are aware of resources such as our urgent care line and external warm lines
• 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
• Assist with facilitating scheduling of appointments, records coordination, or other aspects of care coordination
• 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 good health
• Participate in interdisciplinary care team meetings, huddles and care conferences
• Be responsible for closing assigned tasks and 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
• 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

Requirements for the Role:

• You have experience managing a panel of clients or patients with mental illness and/or substance use disorder
• You have experience with patient and health system navigation, case or care management, or any kind of direct service provision
• Experience working with individuals with mental health and substance use diagnoses
• You have a passion for working within the community you are a part of, or have been a part of in the past
• You excel at empathy and human interactions, and want to improve the health of individuals and 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

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.