Every aspect of the Cityblock care model is carefully designed to focus on our members, engaging and empowering them to own and improve their health through trusted relationships. Through field-based, interdisciplinary care teams, we are flexible in how we deliver care, meeting members where they are, and together developing and working longitudinally through a personalized and integrated Member Action Plan (MAP). The care team collaborates to support each member’s whole health and social needs. Enabled by custom-built technology, we build capacity, deliver care and dramatically change members’ opportunities and outcomes.
Partnering with community-based organizations and a well-respected commercial partner in North Carolina, and backed by the top healthcare investors in the country, we are reorganizing the health system to focus on what matters to our members—and leading the move from transactional, fee-for-service medicine towards high-value, relationship-based partnerships.
In this role, you will provide direct service to Cityblock members as part of our innovative care model, designed to address the complex health and social challenges of high-risk, high-need populations living in urban neighborhoods. You will be a mobile care provider, extending out in the surrounding neighborhood and community. It is integral to our care model that we meet people where they are, both physically and emotionally. Given this, your work will frequently take you out into the community to provide care in settings that work best for our members.
As a Primary Care Physician, you will care for a panel of members in a value-based care environment as part of a tailored interdisciplinary team, driving efforts to improve the health and wellbeing of our members.
• Manage a panel of high-risk seniors and individuals with disabilities, providing diagnosis, treatment, counseling, medication management, acute triage and follow up care
• Identify opportunities to improve individuals’ quality of care, adherence to medications, and closure of preventive care gaps
• Partner with other members of the care team, providing physical health clinical support and collaborating closely with Behavioral Health Specialists and Community Health Partners, among others
• Foster lasting and trusting relationships with individuals, their families and caregivers, and communities
• Work with members longitudinally to achieve their goals.
• Advocate for your members and engage with the community
• Go above and beyond to connect with people 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, members, and family. This platform is optimized for a mobile workforce, and you will use our technology in the field, provide feedback to the product development team, and, over time, become part of a super-user group to assist in onboarding and supporting others
• You are an MD or DO, Board Certified in Internal Medicine, Family Medicine, or Geriatrics with an unrestricted license to practice in the state of North Carolina
• You have experience providing direct care to underserved populations with complex needs -- particularly seniors and individuals with disabilities
• You are an independent self-starter, a leader, and a strategic thinker who is excited about the big picture of whole community health, and the ongoing evaluation and iteration of our care model
• You have experience working within an interdisciplinary team
• You are excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care
• You are passionate about improving care delivery
Nice to have:
• Geriatrics experience
• Palliative care experience
• Experience with home-based care
• Experience working with individuals with co-occurring chronic medical and chronic behavioral health diagnoses.
• Unrestricted North Carolina Driver’s License and vehicle for daily usage
• Multilingual preferred