Cityblock Health

Key Responsibilities

• • 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.
• • 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).
• • 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)
• • 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
• • 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