Population Health Specialist jobs in Cambridge, MA

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:

Behavioral health services and care programming are available to all Cityblock members. The Behavioral Health Specialist (BHS) is part of a dedicated behavioral health care team, and will be available for care team referrals to triage member needs, provide short-term therapeutic interventions, address the needs of members presenting with serious mental illness (SMI) or substance use disorder (SUD), manage behavioral health escalations and help facilitate transitions of care as needed.

• Case Review and Care Planning
  • Participate in case conferences
  • Partner with BH CHP and Psych APC to develop members' care plans
  • Support care team in developing members' care plans when behavioral health interventions apply

• Follow-Up
  • Provide clinical education to members on preventative care topics, including behavioral health and mental wellness
  • Support members' behavioral health needs virtually or in-person
  • (community, home, hub) as needed (e.g., short-term interventions such as collaborative care management)
  • Encourage access to evidenced-based treatments, including long-acting injectable antipsychotics, clozapine, medication assisted treatments (MAT), and contingency management
  • Facilitate behavioral health and SUD referrals with internal and external providers and develop strong relationships with community and external providers
  • Make referrals to care team if medical or social resources are needed
  • Collaborate with the Member Navigator and/or RN Care Manager to determine need for member escalation or placement in a different program (e.g., lower or higher intensity program)
  • Address and respond to member needs and delegate tasks in timely fashion
  • Actively outreach and maintain engagement (e.g., provide behavioral health education) with high-acuity members
  • Support members in achieving their behavioral health care plan goals
  • Assist with behavioral health transitions of care
• Operations and Reporting
  • Utilize our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources
  • Accessible to manage behavioral health crises and to be part of an "on-call" pool during business hours

Requirements for the Role:

• Master's Degree in Social Work or Mental Health Counseling
• Specialty area in Behavioral Health conditions (e.g.,substance use disorders and serious mental illness)
• 2-years post Master's Degree
• Active LICSW license the state(s) practicing
• Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)
• Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management
• Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation
• Versed in Motivational Interviewing, Cognitive Behavioral Therapy and Trauma informed Care principles
• Versed in and able to apply Behavioral Activation Therapy and/or problem solving treatment in practice
• Comfortable providing short-term therapy
• Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members
• Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members' care and health
• Growth and learning mentality, ability to think outside the box, go outside the bounds of "traditional" responsibilities
• Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities

What We'd Like From You:

• A resume and/or LinkedIn profile

Cityblock values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.