Who We Are:

Cityblock Health is a new type of healthcare company, operating out of Brooklyn and backed by Alphabet’s Sidewalk Labs, along with some of the top healthcare investors in the country.

Our mission is to radically improve the health of urban communities, one block at a time. Importantly, our solutions are designed specifically for Medicaid and lower-income Medicare beneficiaries, and we bring the capability to deliver care in the home and neighborhood with our field-based teams.

In close collaboration with community-based organizations and a leading commercial partner, we are reorganizing the health system to focus on what matters to our members. We deliver personalized primary care, behavioral health, and social services through a network of neighborhood hubs with deep community-based partnerships and world-class technology.

We partner with payers and at-risk providers, taking capitated financial risk to care for their most vulnerable, high and rising risk members. Additionally, we invest in strategic partnerships with community-based and social services organizations, in some instances bringing them into the value equation through sub-capitation and performance-based compensation.

Over the next year we’ll grow quickly, including entering new markets, each with their own commercial relationships and field-based teams. This role will be a key contributor to the success of our business.

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 members in the Charlotte region with flexibility to travel to other parts of NC as needed. You will work in a non-judgmental, respectful and empathic manner, to meet member needs, and to provide feedback to the system as a whole as we strive to do better every day.

About the Role:

In this role, you will provide direct service to Cityblock members and co-design a new model of care, as part of our innovative pregnancy program, designed to address the complex health and social challenges of our birthing and postpartum members. It is integral to our care model that we meet people where they are, physically and emotionally. We use a reproductive justice framework, and are highly focused on racial justice and equity in every aspect of our work. Given this, your work will take you out into the community to build trust and relationships with our members with complex needs in the setting that works best for them, and at times, other community-based organizations, health care organizations.

Reporting to the Pregnancy Program Clinical Lead and with a dotted line to the Market Manager of Nursing & Community Care, you will function as a Nurse Care Manager focused on the needs of our high-risk pregnant and postpartum population. You will work collaboratively with a Behavioral Health Specialist and the Clinical Lead/Nurse Midwife who will provide additional clinical oversight for members served by this Pregnancy Care Team. You will provide clinical support to our PCHPs (Perinatal Community Health Partners), the team that serves as the heartbeat of our care model, and will train alongside them in the skills of perinatal, or doula, support in order to more effectively collaborate.

You will:

• Manage a panel of high acuity perinatal members and their neonates, providing longitudinal care through pregnancy and the postpartum period, ongoing chart review, member guidance, education and care planning, home visiting especially following emergency and hospital visits, and review of members at regular case conferences.
• Collaborates with members to create and support progress on care plans that address clinical & social needs in partnership with our Perinatal Community Health Partners, with attention to frequently reassessing needs, coordinating with providers and specialized resources, and cultural resonance.
• Model how to foster lasting and trusting relationships by doing so with your team and your members. Partner closely with our Perinatal Community Health Partners to build trust, informed by principles of birth equity and reproductive justice.
• Aim to spend approximately 20 hours of your time on Direct Member Care (visits). This may be adjusted based on member need.
• Conduct home visits, including scheduled and unscheduled episodic urgent member needs in partnership with Cityblock Health’s Transitions of Care team, providing training to other nurses in the organization to support postpartum home visits
• Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
• Assist members with medication reconciliation, medication administration & medication adherence using shared decision-making skills
• Leverage strong time management skills to to make impactful judgment calls on member care and balance with daily team meetings, weekly case conferences, and skill-building workshops
• Utilize our custom-built care facilitation platform, Commons, and the market’s EMR to collect data, document member interactions in the field, organize information, track tasks, and communicate with your team, members, and community resources

Requirements for the Role:

• Active, unrestricted Registered Nurse license in the state in which you are seeking employment with Cityblock Health
• Deep experience working with perinatal populations; for example, you have worked as a labor and delivery nurse, a community-based home visiting nurse, or in perinatal case management focused on perinatal and NICU needs
• Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with flexibility to work one late evening per week; Work week consists of team meetings, case conference, member EHR chart review, supervision, and field-based independent clinical and co-visits.
• Fiercely committed to highly collaborative support of at-risk populations with complex needs
• enthusiastic about providing in-person, field-based care management, and utilizing creative strategies to meet member needs
• 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 willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals) in the event that a member seeks your support at the bedside
• Proactive problem solver with experience in continuous quality improvement and an interest in equity centered design
• Data driven and able to engage in target setting for clinical initiatives and managing those targets
• Possess exceptional triage, coordination and clinical assessment skills
• Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy), assessment and care plan reinforcement for common problems of pregnancy and the postpartum period, including lactation and chronic conditions such as diabetes, hypertension, depression.
• Demonstrate the ability to affect change, and have been effective in helping a member or patient adapt new habits, or change behaviors
• Excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care.
• Familiarity with community resources and social benefits
• Unrestricted driver’s license and a vehicle available for use

What We’d Like From You:

• A resume and/or LinkedIn profile
• A short cover letter

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.