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Care Coordinator, Transitions of Care - OH (Canton)

Cityblock Health

Cityblock Health

Canton, OH, USA
Posted on Thursday, May 23, 2024

#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:

Cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community. As a TOC Care Coordinator,, you will reach out to members to schedule post-discharge visits, provide care coordination and drive engagement to help ensure that members do not return to the hospital.


  • Receive assignment of members from TOC team
  • Reach out to member/caregiver to schedule post-discharge visit; describe the TOC program expectations and goals


  • Complete assessments following protocols and as needed by the TOC Registered Nurse Care Manager (TOC RNCM)

Case Review and Care Planning

  • Support the TOC RNCM during discharge planning
    • Partner with the TOC RNCM to develop post-discharge care plans that address identified needs and barriers to support a smooth recovery
  • Support members in achieving their care plan goals
    • Bring preliminary goals and identified resources to members to address social and care coordination needs
    • Work with members to address goals in care plans and coach to completion
    • Focus on members’ goals, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs
  • Participate in case conferences upon member discharge to discuss 30-day readmission mitigation plan
  • Collaborate with TOC RNCM for hand-off to longitudinal care at conclusion of the TOC program
  • Collaborate with TOC team to determine need for escalation of member care


  • Weekly check-ins with members to follow-up on post-discharge care plan needs and progress
  • Provide care coordination (e.g., benefits, social needs, external care) with the member/caregiver, internal care team and external providers
  • Provide routine non-clinical education on preventative care topics
  • Address and respond to member needs and delegate tasks in timely fashion
  • Meet with members in the community (home, SNF, IRF, shelter, hospital) as needed, including as an extender of the care team for non-clinical needs
  • Complete screenings for emerging needs
  • Refers members to the TOC RNCM for clinical needs, while including other internal collaborators as necessary (e.g., pharmacy team, Behavioral Health Team, Mobile Integrated Care Team)
  • Support loop closure on internal referrals

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
  • Track TOC metrics for assigned members and log new TOC events and accompanying follow-up metrics.

Requirements for the Role:

  • HS Diploma
  • At least 1-2 years of experience in community care or care coordination required
  • Unrestricted Driver’s License and vehicle for daily use
  • 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
  • Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner
  • Versed in Motivational Interviewing and Trauma Informed Care principles
  • 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.

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.