In close collaboration with community based organizations and leading commercial partners, we are reorganizing the health system to focus on what matters to our members. We deliver personalized primary care, behavioral health, and social services through a network of neighborhood hubs with deep community-based partnerships and world-class technology.
Over the next year we’ll expand quickly, growing from 2 to over 10 Neighborhood Hubs, and this role will be a key contributor to the success of the new business.
In this role, you will be a part of the first clinical leaders overseeing and providing direct services to members who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. In addition to direct care, you will provide clinical oversight and leadership to field- and hub-based care teams delivering integrated care to our members. Your work, and that of the teams you oversee, will take you out into the surrounding community. You will also play an important role in informing ongoing iterations and enhancements to our care model, ensuring that it is effectively tailored to meet the needs of our members, and that our custom-built care facilitation platform, Commons, is fully configured to support and enhance the model.
As a medical director, you will be responsible for providing clinical oversight to interdisciplinary care teams, collaborating with our partners, and leading the development of clinical practice guidelines. This includes ensuring appropriate clinical supervision of advanced practice clinicians, spearheading clinical quality and performance improvement initiatives, clinical risk management, achieving practice-level and individual patient quality outcomes, and supporting clinical best practice adoption with specific focus on providing appropriate care to frail elderly patients and furthering the integration of behavioral health and primary care services. You will provide clinical supervision to home-visiting nurse practitioners, physician assistants, and nurses who are managing members with complex physical, cognitive, and behavioral health needs as a part of an interdisciplinary care team. As a participant in your panel’s care team, you will provide clinical support to the care team, including Community Health Partners, who will serve as a member’s main point-of-contact, and leading the development of a personalized Member Action Plan (MAP). Additionally, you will participate in out-of-hours on-call duties, as well as phone availability for triage and case discussion with other clinicians on the care team.
• Oversee teams that provide full-spectrum facility-based, community/home, and virtual primary care to a panel of members across the complexity and risk spectrum, with an emphasis on evidence-based preventive care, chronic disease management, primary behavioral health and primary palliative care
Interface with specialists, hospitals, and community based organizations to promote an understanding of Cityblock’s model, facilitate collaboration, and promote effective patient co-management
• Provide clinical oversight and supervision for advanced practice clinicians assigned to members in your North Carolina market
• Foster lasting and trusting relationships with members and their family members, to assist members in achieving their goals, identifying new needs, and coordinating care.
• Play a lead role in monitoring, evaluation, and quality improvement activities, including review of member and care team quality of care concerns.
• Drive program development and integration of clinical innovations, including, where applicable, community paramedicine, care transitions, telemedicine, palliative care, and others.
• Participate in the development and delivery of educational content around primary care, , chronic disease management, and integration of primary and behavioral health needs.
• Assist in training and mentoring new employees as needed.
• Participate equally in all call responsibilities.
• Go above and beyond to connect with patients 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, Commons, which will enable you to collect data, organize information, track tasks, and communicate with staff, patients, and family. This platform is built for a mobile workforce, and you will field-test our technology, provide feedback to the product development team, and, over time, become part of a super-user group to assist in on-boarding and supporting others.
• Attend external meetings and activities, and maintains professional credentialing and CME standards.
• You have an MD or DO degree from an Accredited institution.
• Board Certified or Board Eligible in Family Practice, Internal Medicine,
Pediatrics, Medicine/Pediatrics or Geriatric Medicine
• Active medical license in good standing in the State of North Carolina
• You have led practices, care teams, and held administrative roles in innovative care models
• You have experience providing clinical services to individuals with co-occurring chronic medical and behavioral health conditions, and have an interest in serving complex, vulnerable, and disabled populations.
• Proven skills, knowledge base, and judgment necessary for independent clinical decision-making.
• You are an organized, efficient, independent self-starter and problem-solver, a leader, a strategic thinker, and a mentor, who is excited about the big picture of whole community health.
• You are excited about how technology can support your work and help drive the ongoing evaluation toward new and better care.
Nice to have:
• You have experience with quality improvement, monitoring and evaluation, health systems strengthening, innovation and training.
• Experience working collaboratively with an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff.
• North Carolina Controlled Substance Registration
• DEA-approved to provide buprenorphine treatment for substance use disorder
• Unrestricted North Carolina Driver’s license and vehicle for daily usage