Nurse Practitioner (NP) or Physician Assistant (PA) - Mainly remote - San Antonio, TX OR Dallas -Forth Worth, TX

Job Description:

Currently mainly virtual role, but this individual will need to live be local to one of the following areas: San Antonio, TX, Dallas -Forth Worth, TX (DFW) area.

Working hours: Apx. 8AM - 5PM CST M-F (no nights, weekends or holiday)

About the Role:

The Cityblock Longitudinal Care Provider serves as a practice-based provider, supporting members with scheduled appointments, walk-ins and urgent or emergent visits across multiple modalities (Face to Face or virtually; in a hub, community or home setting). The Pod Provider delivers comprehensive chronic disease management (e.g. hypertension, diabetes, chronic kidney disease), evaluation of acute concerns, behavioral health condition management (i.e. depression, anxiety, alcohol and substance use disorder), and preventative care and wellness support (including sexual and reproductive health). The role works collaboratively with an interdisciplinary team of clinical and non-clinical members to develop member care plans and to support members throughout their care journey. The Pod Provider also assists with the development and enhancement of clinical programs, initiatives, processes, and policies.

Responsibilities:

Clinical Visits

• Conduct comprehensive clinical intake visits for selected members (based on member segmentation, program empanelment and care team recommendation).

• Conduct timely follow-up for members post transition of care event, acute need or according to condition-specific needs.

• Proactively outreach to members who need follow up care.

• Provide clinical care in line with  CBH protocols.

• Complete comprehensive and compliant diagnosis capture related to HCC (Hierarchical Condition Categories) and ICD-10 (International Classification of Diseases-10) Coding.

• Address 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.

• Address and respond to member needs and delegate tasks in a timely fashion.

• Finish documentation according to company timelines (within 48 hours of clinical encounter) company policy.

Clinical Scope

• Prescribe 1st and 2nd line medications for depression, anxiety, alcohol use disorders and opioid use disorders.

• Continue psychiatric medications for members with stable SMI 

• Remain up to date on evidence-based care for complex patients in primary care: (adult only, pediatric in certain markets). Provide longitudinal direct primary care or wrap-around care with focus on chronic condition management and preventative care.

• Refer member to specialist care appropriately and according to internal CBH guidance if available.

• Support the member in achieving the goals in their care plans (physical, behavioral, and/or social health).

Case review and care planning

• Participate in case conferences with the care team, providing clinical expertise on care plan development.

• Provide guidance on highest impact clinical interventions and tasks to achieve a member’s goals.

Panel management

• Collaborate on a panel of members to provide clinical input, including health maintenance, chronic disease management and co-occurring psychiatric disorder support

• Collaborate with care team to determine need for member placement in a different program (e.g., lower or higher intensity program)

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

Leadership

• Educate, support and elevate team members’ own skills (informal coaching is a significant part of collaborative practice)

• Market Medical Director, Associate Medical Director, Community Health Partner (CHP), Behavioral Health CHP, Psychiatrist, Pharmacist, RN Care Manager, Behavioral Health Specialist

Requirements for the Role:

• Education & License requirements

  • Completed an accredited NP or PA program with a national certification 

  • Specialty Area requirement: Family, Geriatrics, Adult, or Primary Care