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. The TOC Registered Nurse Care Manager (RNCM) coordinates with hospital case managers to determine members’ needs and to complete discharge visits (in-home or virtual) with members and providers. The TOC RNCM will also be available for referrals to triage members’ needs and provide clinical education, with the goal of helping ensure that members do not return to the hospital.

Responsibilities:

Engagement

• Receive assignment of members

• Reach out to hospital case manager to understand member needs

• Reach out to member to engage for TOC program

Assess/Intake

• Complete self-efficacy and relevant condition-specific screeners with members

  • Complete additional tools or screeners as needed, including relevant behavioral health screeners (e.g., PHQ9, GAD-7, AUDIT, DAST-10)

• Triage members with need for behavioral health programming

• Conduct an in-person clinical exam, if appropriate

• Collaborate with care team members to determine need for member placement in a different program (e.g., lower or higher intensity programs)

Case Review and Care Planning

• Participate in daily inpatient rounds (while member is admitted) and case conference (once member is discharged)

• Discharge planning

  • Partner with the TOC Care Coordinator and TOC Behavioral Health Specialist (as needed) to develop post-discharge care plans that address identified needs and barriers to support a smooth recovery

• Collaborate with TOC team for hand-off to longitudinal care at conclusion of the TOC program

• Collaborate with TOC team to determine need for escalation of member care

Clinical Visits and Follow-Up

• Regular check-ins with member as guided by TOC program

• Complete post-discharge home visit

• Weekly follow-up for four (4) weeks

• Ensure provider visit takes place (can be facilitated during home visit)

• Address and responds 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

• Conduct comprehensive medication reconciliation

• Address contracted and company prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure

Operations

• 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

• Manage the tracking of all metrics related to transitions of care for assigned members including logging new TOC events and accompanying follow up metrics.

Requirements for the Role:

• Must have at least 3 years nursing experience. Prefer some hospital experience. Up to 50% travel during the week within the community. Must be ok with going into homes/facilities.

• Graduate of an accredited school of nursing (R.N.)

• Basic Life Support (BLS) certification is a requirement

• Active RN License in the state(s) practicing

• Unrestricted Driver’s License

• Medical Clearance - evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation from vaccination if necessary

• Proof of COVID Vaccination - proof of receipt of a primary COVID vaccination series, or have an approved medical or religious accommodation from vaccination if necessary

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.

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:

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.