Home-Based Primary Care NP/PA — Chronic Disease Focus

Cityblock; Charlotte, Northern (NC, KY); Hybrid; USD 130,000 - 140,000; Full time

Benefits offered by this job

Health insurance

Life insurance

Retirement benefits

Equity program

Paid time off (vacation and sick leave

Job summary

Cityblock Health is seeking a Pod Provider to deliver comprehensive chronic disease management and preventive care through our home- and community-based model. You will work with an interdisciplinary team to develop member care plans and support their care journey, including behavioral health and social needs.

You will engage in case conferences, ensure proper documentation and coding, and contribute to clinical programs that improve outcomes for Medicaid and lower-income Medicare populations.

Qualifications

• 3+ years of clinical experience in primary care or chronic disease management.
• Experience collaborating with interdisciplinary teams to develop care plans.
• Proactive outreach to ensure follow-up and gap closure in patient care.

Responsibilities

• Conduct comprehensive intake visits and provide longitudinal care for chronic conditions.
• Proactively outreach to members needing follow-up care.
• Document diagnoses and coding for accuracy (ICD-10/CPT) and support quality gaps.
• Prescribe appropriate medications for depression, anxiety, and substance use disorders when appropriate.
• Participate in case conferences and contribute clinical input to care plans.

Skills

Chronic disease management

Primary care

Behavioral health

Job description

Cityblock Health is seeking a Pod Provider to deliver comprehensive chronic disease management and preventive care through our home- and community-based model. You will work with an interdisciplinary team to develop member care plans and support their care journey, including behavioral health and social needs.

You will engage in case conferences, ensure proper documentation and coding, and contribute to clinical programs that improve outcomes for Medicaid and lower-income Medicare populations.