Bilingual Care Pod Physician-Orlando, FL

Job Description:

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:

The Clinical Delivery team radically improves healthcare by meeting members where they are to identify and address health needs. The Pod Provider (MD/DO)role radically improves healthcare by serving as the primary care or wrap-around provider for members in Cityblock’s unique, interdisciplinary care model.

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.

• Weekend and on-call duties may be assigned depending on market needs.

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 preventive care.

• Refer members to specialist care appropriately and according to internal CBH guidance if ava