Cityblock Health

Dispatcher

• Screen requests for services from members.
• Coordinates assignment and flow of field and virtual care resources across several states.
• Identifies and highlights issues of safety, service delivery, continuity of operations and escalates as necessary.
• Identifies risks of imminent life threats, self-harm or harm to others and directs questioning.

Dispatcher, EMT/Paramedic

Manager

• The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members.
• The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy.
• Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals.
• Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs.
• Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity.
• Prepare for and actively participate in case conferences, leading discussions when necessary.
• Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner.
• Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly.
• Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support.
• Perform medication reconciliation, administration, compliance, and education as part of member care.
• Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures.
• Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources.
• Support members in achieving their care plan goals through coordinated and comprehensive care efforts.

RN Care Manager

Affiliate Manager

• Provides support to both our Community Health Partners (CHPs) and Care Team Lead
• Partners with the Care Team Lead and the Pod’s clinical team to run daily huddles
• Provides guidance, coaching, and training around engagement, care planning, and longitudinal care
• Maintain a panel of members; acts as a point person for these members and partners with them longitudinally in attaining their goals

Senior Community Health Partner

• Responsible for the day-to-day execution of operational workflows that drive value-based care results
• Influences through others, ensuring that market-specific initiatives—like member outreach, gap closure, and provider scheduling—are executed with precision
• Oversees the daily "ground game" of market operations, ensuring that workflows are completed on time and accurately
• Tracks team performance against weekly and monthly KPIs; identifies bottlenecks in workflows
• Acts as a bridge between frontline staff and market and central team leadership, ensuring that barriers to care are escalated and resolved quickly

Manager, Market Performance

Director

• The Sr. Director, Market Performance is responsible for the operational health and financial performance of Cityblock’s Value-Based Care (VBC) ecosystem within an assigned market(s).
• This role bridges the gap between enterprise strategy and local execution, leading through others to ensure care delivery models and payer partnerships are integrated and efficient.
• In partnership with regional market leadership, the Sr. Director drives P&L performance by applying broad industry knowledge to resolve complex business problems.

Senior Director, Market Performance

Data Analyst

• Partner with senior leaders across operations, product, and clinical teams to transform data into strategy and business needs into analytics solutions
• Own and grow dbt-based infrastructure to support operational workflows while utilizing development best practices
• Design and analyze experiments (A/B and multivariate) to measure effectiveness
• Improve attribution logic using best practices in analytics
• Build compelling visualizations and dashboards to support decision-making
• Collaborate with other data analysts on shared infrastructure and cross-functional deliverables
• Leverage Generative AI, Large Language Models (LLMs), and prompt engineering to build conversational analytics tools, automate insights, and enhance natural language data querying capabilities.

Senior Data Analyst, Advanced Analytics

Physician Assistant

• Deliver comprehensive chronic disease management
• Evaluate acute concerns and manage behavioral health conditions
• Collaborate with an interdisciplinary clinical team
• Conduct longitudinal direct primary care

Nurse Practitioner, Physician Assistant

Pharmacist

• Collaborates with comprehensive interdisciplinary roles as part of a managed care team
• Provides medication reconciliation, access, adherence, and affordability services
• Connects Cityblock members and care teams to pharmacy resources and support enrollment in qualifying copay assistance programs
• Acts as a medication therapy liaison and navigator for the member, the Cityblock care team, external providers, and the health plan
• Serves as a clinical pharmacist extender, performing administrative and clinical support tasks to enhance the delivery of comprehensive medication management services
• Schedules members referred or identified as eligible for initial pharmacist consult visits; performs reminder phone calls and appointment rescheduling as necessary
• Assists with verifying medication list details and alerts the pharmacist of discrepancies as per clinical protocol

Pharmacy Care Navigator

Clinician

• Provide behavioral health support to members in an in-person and virtual setting.
• Develop member care plans for members when behavioral health interventions are needed.
• Provide clinical education to members on preventative care topics, including behavioral health and mental illness.
• Make appropriate referrals for medical support, social resources, behavioral health and Substance Use Disorder (SUD) to external and internal providers or internal care team.
• Collaborate with internal care teams to assess and determine need for member escalation or placement in different programs (e.g., lower or higher intensity program).
• Maintain engagement with high-acuity members.

Behavioral Health Clinician, LCSW/LMHC

• Manages a panel of clinically complex members to support clinical programs
• Collaborates with members to create and oversee care plans
• Completes screenings to identify behavioral health needs
• Conducts clinical examinations and participates in case conferences
• Develops care plans addressing social needs and follow-ups on clinical visits
• Performs medication reconciliation and supports quality gap closures

• Responsible for day-to-day execution of operational workflows that drive value-based care results
• Influences through others, ensuring market-specific initiatives are executed with precision
• Analyzes market operations execution, member utilization patterns, and care model to identify areas of opportunity
• Oversees the daily 'ground game' of market operations, ensuring workflows are completed on time and accurately
• Tracks team performance against weekly and monthly KPIs; identifies bottlenecks in workflows
• Acts as a bridge between frontline staff and market and central team leadership, ensuring barriers to care are escalated and resolved quickly

• Manages a panel of clinically complex members to support impactable clinical programs, quality gap initiatives and ED and IP utilization
• Collaborates with members to create a care plan and oversees progress to the plan
• Completes self-efficacy and condition-specific screeners during the assessment and intake phase
• Refers members to behavioral health programs as needed
• Develops a care plan in collaboration with the member, addressing social needs
• Conducts regular clinical visits and follow-ups per clinical program and pathway guidelines
• Performs medication reconciliation, administration, compliance, and education as part of member care
• Utilizes care facilitation tools, electronic health records, and scheduling platforms to gather data

• manages a member panel to support care coordination and social care for high-complexity members
• conducts assessments and screening instruments
• collaborates with psychiatrists, RNs, and Behavioral Health Specialists for case review and care planning
• meets with members in the community as needed
• utilizes care facilitation, electronic health record, and scheduling platforms as needed

Behavioral Health Community Health Partner

• Provide Comprehensive Medication Management (CMM) in collaboration with hub-based and virtual clinical care teams and provide other pharmacist support services as needed.
• Contribute in the development of a medication management action plan to achieve member self-management goals and clinical outcomes, with measurable parameters and timeline for monitoring and follow-up.
• Communicate and work collaboratively with Cityblock and external providers belonging to member care team to ensure all clinical interventions and encounters are aligned with medication-related goals, and conduct ongoing assessments and refinements to care plan necessary to promote goal attainment.
• Provide direct support to clinical team members for all general drug information, dosing, interaction/adverse effect avoidance questions or member-specific needs.
• Participate in staff education through presentation of medication management in-services, development of educational tools for clinical and non-clinical team members, and training/coaching/facilitating all roles on consistent maintenance of a member’s best possible medication list care management platform, Commons, as well as post-discharge med reconciliation process for providers.
• Help develop medication management and disease state-specific clinical pathways/protocols, with the eventual goal of transitioning to collaborative practice agreements (CPA) with Cityblock physicians, permitting pharmacist to perform member assessments, order laboratory tests, and initiate or adjust medications per protocol to improve the efficiency and effectiveness of team-based care.

Ambulatory Care Clinical Pharmacist – OH, MI, IL

• Meets with members in the community (home, short-term nursing facility shelter, hospital) as needed, including as an extension of the care team
• Cares for members, identifying and addressing their barriers to and social influences on optimal health.
• Coordinates care for a case load of members, identifying and addressing their barriers to and social influences on optimal health.