Home-Based Primary Care NP/PA: Chronic & Behavioral Health

Cityblock Medical Practice, P.A.; Charlotte (NC); Remote; USD 130,000 - 140,000; Full time

Benefits offered by this job

Health insurance

Retirement benefits

Equity program

Paid time off

Job summary

Cityblock Health is seeking a Pod Provider to deliver comprehensive chronic disease management, evaluation of acute concerns, and behavioral health support. You will work with an interdisciplinary team to develop member care plans and support members throughout their care journey, including program development and policy enhancement.

The role emphasizes direct primary care, preventative care, and population health within a field-based, home-based care model.

Qualifications

• Minimum 3 years of clinical experience.

Responsibilities

• Conduct comprehensive clinical intake visits.
• Provide longitudinal direct primary care or wrap-around care with focus on chronic condition management and preventative care.
• 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.
• Complete comprehensive and compliant diagnosis capture related to HCC and ICD-10 Coding.
• Address contractual and company-prioritized quality gaps and ensure proper chart documentation and codes are included in the encounter as supporting evidence of gap closure.
• Prescribe 1st and 2nd line medications for depression, anxiety, alcohol use disorders and opioid use disorders.
• Remain up to date on evidence-based care for complex patients in primary 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.
• 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.
• Collaborate on a panel of members to provide clinical input, including health maintenance, chronic disease management and co-occurring psychiatric disorder support.

Job description

Cityblock Health is seeking a Pod Provider to deliver comprehensive chronic disease management, evaluation of acute concerns, and behavioral health support. You will work with an interdisciplinary team to develop member care plans and support members throughout their care journey, including program development and policy enhancement.

The role emphasizes direct primary care, preventative care, and population health within a field-based, home-based care model.