Job Description:

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.

Engagement

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

Assessments/Intake

• 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

Follow-up

• 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

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.

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.

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.