The Population Health Partner (PHP) supports members with low medical complexity by helping them navigate health and social care resources. They assist in clarifying health-related priorities, connecting members to internal and external services, and triaging higher-level needs, including behavioral health concerns. The role focuses on addressing health-related social needs while also supporting care teams in securing medical, dental, and vision services, optimizing benefits, and ensuring members remain healthy at home.

This is an entirely virtual role, requiring excellent organizational, communication, triage and data management experience, customer service skills, as well as proficiency using a range of technology platforms, and comfort working efficiently and effectively without

Responsibilities:

Member Engagement & Orientation – Receive members from engagement and care teams, explaining program expectations, duration, and goals, including care pathways and social needs.
Assessments & Intake – Complete assessments and screenings (including for behavioral health disorders) following protocols; collaborate with the RN Care Manager to determine appropriate program placement.
Care Planning & Goal Setting – Partner with the RN Care Manager to develop, refine, and adjust care plans based on member needs and quality improvement opportunities.
Care Coordination & Coaching – Support members in achieving and modifying care plan goals, focusing on risk mitigation, provider engagement, and addressing social needs.
Follow-Up & Member Support – Conduct ongoing check-ins to ensure progress on care plan goals, follow up on care coordination needs, and activate members around preventative care topics.
Referrals & Escalations – Identify emerging needs through screenings, refer members to appropriate care team resources, and support internal referral loop closure.
Operations & Documentation – Utilize Cityblock’s care facilitation, EHR, and scheduling platforms to document interactions, track tasks, and coordinate communication across teams.

Work Experience:

2+ years of relevant experience

Education:

High school degree

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is:

$27.40 – $35.10 Hourly

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.

Medical Clearance (for Member-Facing Roles):

You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases.

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