Case Manager - Barnstable

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:

Community Health Partners (CHP) work closely with RN Care Managers to support integrated social care for members with complex health needs (social, behavioral and physical). CHPs are responsible for care coordination, spending significant time visiting members (telephonic, virtual, Hub, or in-home), helping members navigate community-based and social services, coordinating medical care with both internal Cityblock and external providers.

Engagement

• Receive members from engagement and care teams
• Describe program expectations (e.g., length) and goals to members

Assessments/Intake

• 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)

Case Review and Care Planning

• 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

Follow-up

• 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, SNF, shelter, hospital) 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)

Operations

• 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

Requirements for the Role:

• HS Diploma
• At least 1-2 years of experience in community care or care coordination required
• Unrestricted Driver's License and vehicle for daily use
• Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)
• Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management
• Understanding of how to use electronic health record systems and/or 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

What We'd Like From You:

• A resume and/or LinkedIn profile

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.

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We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.