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Manager, Nursing, Transitions of Care - OH

Cityblock Health

Cityblock Health

Posted on Friday, September 8, 2023

#communityhealth #healthcare

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:

The Transitions of Care (TOC) Nurse Manager is a highly specialized and skilled RN, who is primarily responsible for accompanying, coaching, managing and supporting the medical, behavioral and social care needs of our members, both pre-consented or consented, as the member transitions through healthcare settings to their home, ensuring the member has what they need to be able to stay safe and at home.

More specifically, the TOC Nurse Manager will lead the Market Transitions of Care team that is accountable for managing members during an ED visit, inpatient stay, post-acute facility stay, immediate post-discharge to the member’s home and the following 30 days. They will respond in real-time to any readmissions that occur during this time frame. This person will directly impact and adhere to the readmission rate goals and other KPI’s set by the organization, ensuring better member experience, lower morbidity, mortality and hospital utilization, reducing total cost of care.

You will provide clinical, operational and managerial support to the TOC team to ensure care coordination, quality care management, positive member health outcomes, and Transitions of Care support. You will work with a small panel of members as needed to improve their health holistically.

Key Responsibilities:

  • Supervise and Manage a team of RNs and Community Health Partners (CHPs), Behavioral Health (BH) Case Managers, BH CHPs, and other market-specific roles that support TOC operations (that could also include TOC medical Assistants, CTOAs, etc)
  • Responsible for ensuring that the TOC model (and interventions) are executed as intended, ensuring evidenced-based interventions result in better member health and social outcomes and are aligned with the member’s values and preferences
  • Responsible for the implementation of TOC interventions in accordance with existing federal, state, local and payor standards and compliance requirements.
  • Ensure clinical and operational KPIs are met, resulting in reduced readmission, ED utilization and overall reduction of total cost of care
  • Oversight of education for medical CMS criteria for members when entering the hospital, post-acute care facilities and/or community-based medical needs
  • Provide education to physicians, case managers and other team members on issues related to utilization review; including inappropriate admissions and placements
  • Work closely with the Senior Coordinators and Senior RNCMs to manage the team’s daily huddles and weekly case conferences
  • Ensure the efficiency and maintenance of the TOC huddle tracker to support members as they transition through health care settings
  • Assist your team in using the Case Management Platform and Electronic Health Record systems
  • Supervise the completion of comprehensive assessments of members’ health needs, including physical, behavioral, and social
  • Educate and ensure the development of appropriate member-centered care plans with SMART goals and weekly interventions in the modality appropriate for the member's risk
  • Responsible for providing assistance in complex cases and escalating events for members with urgent needs
  • Works daily within the Care Management platform to collect data, organize information, track tasks, and communicate with staff, patients, and family.
  • Responsible for providing coaching to the TOC team around engagement, care planning, and longitudinal care. In addition, this role will review individual performance and outcomes metrics.
  • Occasionally provide direct care for members undergoing a TOC event (likely in the event of opportunities for training and coaching or any other situation that will ensure appropriate functioning of the TOC team at all times)

Requirements for the Role:

  • Current, unrestricted RN license in the state of practice and ability to obtain additional licensure if required.
  • 5+ years of clinical experience in an acute care, home health, hospice, geriatric and/or hospital setting
  • 3+ years directly managing a team of RNs (or higher clinical training)
  • CCM certification preferred
  • Experience using EMR and CM practice guidelines
  • Experience leading the day-to-day operations of interdisciplinary teams
  • Knowledge of discharge planning alternatives options and interdisciplinary approaches
  • Possess exceptional triage, coordination and clinical assessment skills
  • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
  • Independent self-starter, a leader, and a strategic thinker who is excited about the big picture of whole community health, and the ongoing evaluation and iteration of our care model
  • Familiarity and willing to travel within the community (home-based member visits) and its healthcare systems (hospitals and rehab centers)
  • Access to reliable transportation that will enable you to travel to client and/or patient sites within the assigned care area.
  • Experience as an active participant in continuous quality improvement projects within a provider setting
  • Experience working with special needs plans and/or Medicare Accountable Care Organization preferred
  • Knowledge of Medicare and Medicaid benefit products including applicable state regulations preferred
  • Experience with CMS, URAC and NCQA preferred
  • Bilingual (English/Spanish) preferred

What We’d Like From You:

  • A resume and/or LinkedIn profile
  • A short cover letter, please!

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.

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.

Covid 19 Update - Please Read:

Cityblock requires those hired into this position to provide proof that they have received the COVID-19 vaccine. Any individuals subject to this requirement may submit for consideration a request to be exempted from the requirement (based on a valid religious or medical reason) on forms to be provided by Cityblock. Such requests will be subject to review and approval by the Company, and exemptions will be granted only if the Company can provide a reasonable accommodation in relation to the requested exemption. Note that approvals for reasonable accommodations are reviewed and approved on a case-by-case basis and availability of a reasonable accommodation is not guaranteed. This vaccination requirement is based, in part, on recently established government requirements. The requirement is also based on the safety and effectiveness of the vaccine in protecting against COVID-19, and our shared responsibility for the health and safety of members, colleagues, and community.

The COVID-19 pandemic has severely impacted the health and lives of people around the world, including the vulnerable populations Cityblock serves. As a healthcare provider, Cityblock holds ourselves to the highest standards when promoting the health and safety of those who we serve. Given that the COVID-19 vaccines are one of the most powerful tools to fight this disease and save lives, Cityblock is implementing a COVID-19 booster mandate for Washington, D.C. employees under the guidance of local/state mandates.