Cityblock Health

Bilingual

• Serve as a practice-based provider supporting members through scheduled appointments, walk-ins, and urgent or emergent visits across face-to-face and virtual modalities in a hub setting
• Deliver comprehensive chronic disease management for conditions including hypertension, diabetes, and chronic kidney disease
• Evaluate acute concerns and manage behavioral health conditions including depression, anxiety, and alcohol and substance use disorders
• Provide preventative care and wellness support, including sexual and reproductive health
• Conduct comprehensive clinical intake visits and timely follow-up visits
• Proactively outreach to members needing follow-up care
• Provide clinical care according to CBH protocols
• Complete HCC and ICD-10 diagnosis capture and address quality gaps with appropriate ICD or CPT documentation
• Address member needs and delegate tasks in a timely manner
• Complete clinical documentation within 48 hours of the encounter
• Prescribe first- and second-line medications for depression, anxiety, alcohol use disorders, and opioid use disorders
• Refer members to specialist care according to internal guidance
• Support members in achieving physical, behavioral, and social health goals
• Participate in case conferences and provide clinical expertise for care plan development
• Provide clinical input on health maintenance, chronic disease management, and co-occurring psychiatric disorders
• Collaborate with care teams on member program placement
• Use care facilitation, electronic health record, and scheduling platforms to document interactions, track tasks, and communicate with teams, members, and community resources
• Educate, support, and elevate team members through informal coaching
• Act as collaborating physician overseeing Advanced Practice Clinicians
• Complete chart reviews in compliance with CBH policy
• Guide clinical teams on complex cases and provide point-of-care escalation support and clinical consultation

Bilingual Primary Care Physician

Social Worker

• Triage member needs through care team referrals
• Provide short-term therapeutic interventions
• Address members presenting with serious mental illness (SMI) or substance use disorder (SUD)
• Manage behavioral health escalations
• Facilitate transitions of care as needed
• Provide behavioral health support to members in in-person and virtual settings
• Develop member care plans when behavioral health interventions are needed
• Provide clinical education on preventative care topics, including behavioral health and mental illness
• Refer members to medical support, social resources, behavioral health, and Substance Use Disorder (SUD) providers or care teams
• Collaborate with internal care teams on member escalation or placement in different-intensity programs
• Maintain engagement with high-acuity members

Bilingual Primary Care Physician

Licensed Clinical Social Worker, Behavioral Health