Community Health Partner at Cityblock Health

Detroit, Michigan, United States

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Not SpecifiedCompensation

Entry Level & New Grad, Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Social ServicesIndustries

Requirements

Bachelor's Degree
2+ years of progressive experience in social work, care coordination, community health, health promotion, or a related field
Experience with High Volume Caseload
Unrestricted Driver’s License and vehicle for daily use
Proficiency using technology to support members with and without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)
Ability to learn and use scheduling platforms to ensure accurate appointment scheduling and management
Ability to learn and use care facilitation platforms to ensure accurate documentation
Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner
Versed in Motivational Interviewing and Trauma Informed Care principles
Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members
Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members’ care and health
Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities
Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities

Responsibilities

Receive members from engagement and care teams
Describe Cityblock program expectations (e.g., length) and goals to members
Complete assessment and screening instruments (including for behavioral health disorders) following protocols
Collaborate with RN Care Manager to determine need for member placement in a different program (e.g., lower or higher intensity program)
Partner with the RN Care Manager to develop members’ care plans
Incorporate quality opportunities in care plans
Support members in achieving their care plan goals
Bring preliminary goals and identified resources to members to address social and care coordination needs
Work with members to address goals in care plans and coach to completion
Focus on goals of the members, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs
Participate in case conferences
Ongoing check-ins with members to follow-up on care coordination needs (benefits, social needs, external care) and care plan progress
Activate members around preventative care topics and goal progress
Provide routine non-clinical education on preventative care topics to members
Address and respond to member needs and delegate tasks in timely fashion
Meet with members in the community (home, shelter, etc.) as needed, including as an extender of the care team for non-clinical needs
Complete screenings for emerging needs
Referral to care team if clinical interventions needed
Support loop closure on internal referrals (e.g., Behavioral Health Specialist, Pharmacists, Mobile Integrated Care team)
Utilize 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

Skills

care coordination

case management

behavioral health assessments

social services navigation

care planning

member engagement

preventative care education

community outreach

Cityblock Health

Personalized healthcare services for Medicaid patients

About Cityblock Health

Cityblock Health provides personalized healthcare services primarily for Medicaid patients, focusing on compassionate care that addresses both medical and non-medical needs. When individuals join Cityblock, they are assigned a dedicated care team that includes doctors, nurses, mental health advocates, and social workers, all tailored to meet their specific health requirements. This team helps members navigate their healthcare journey, from finding specialists to providing urgent care services for non-life-threatening emergencies, delivered right at their homes. Cityblock distinguishes itself from competitors by emphasizing a holistic approach to health, which includes support for housing, food security, addiction treatment, and childcare, in addition to traditional medical services. The company's goal is to ensure that every member receives comprehensive care that respects their individual stories and circumstances, making healthcare accessible and compassionate.

New York City, New YorkHeadquarters

2017Year Founded

$890MTotal Funding

LATE_VCCompany Stage

HealthcareIndustries

501-1,000Employees

Benefits

Comprehensive health, dental, & vision coverage

12 weeks parental leave

401(k)

20 days vacation

Company retreats & events

Risks

Over-reliance on Medicaid funding poses financial risks with policy changes.

Rapid expansion may strain resources and affect service quality.

Continuous IT investment is needed, posing a financial burden if not aligned with growth.

Differentiation

Cityblock Health offers a unique care model integrating medical and social services.

The company focuses on Medicaid patients, addressing complex health and social needs.

Cityblock's Advanced Behavioral Health Program shows significant cost savings and reduced utilization.

Upsides

Partnerships in North Carolina and Florida expand Cityblock's reach in high Medicaid areas.

The ABH Program's success suggests potential for expansion and replication in other regions.

Cityblock's flexible care model enhances accessibility and patient satisfaction.

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