Care Coordinator, Transitions of Care - OH (Canton)

Cityblock Health

Cityblock Health

Canton, OH, USA
Posted on Thursday, August 31, 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:

As a Transitions of Care (TOC) Community Health Partner (CHP), you provide direct care coordination services to members, who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. You will go above and beyond to connect with members in all Cityblock markets that have a Transitions of Care Event 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.

In this role, you will coordinate with the member, their TOC RN Case Manager (TOC RN CM), and the internal Cityblock Care Teams to ensure a safe transition from the healthcare setting to their home, and ensure they do not return to the hospital. This role will be a part of the 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’s experience, lower morbidity, mortality and hospital utilization, reducing total cost of care.


  • Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including in partnership with the TOC RN CM.
  • Support our members during their time of increased need and is accountable for developing (in collaboration with the TOC RN CM), implementing, and evaluating comprehensive TOC interventions that are evidenced-based but aligned with the member’s values and preferences
  • To follow a panel of members who have had a recent transition of care episode, coordinate all aspects of their care through in-person, telephonic or video interventions.
  • Engage patients in person, virtually and/or telephonically in different settings, specially in the hospital setting and at home, depending on the patient risk assessment, needs and market preference based on the population served.
  • Assist health care staff (in the ED, inpatient setting, post-acute and community settings), under the guidance of the TOC RN CM, in creating the discharge plan that will address identified needs and barriers to support a smooth recovery; assess if the member can be discharged.
  • Support the TOC RN CM to perform a post-discharge home visit, and ensure follow-up with a post discharge provider and other providers.
  • Attend daily TOC inpatient clinical rounds prepared to assist the TOC RN Care Manager to present admissions, discharges and complex members.
  • Coordinate care for members, identifying and addressing their barriers to and social influences on good health. Responsible for implementing specific readmission prevention activities targeting Social Determinants of Health that may be driving hospital utilization, in collaboration with the TOC team. These include and not limited to: housing and food security, transportation, medication access and affordability, caregiving and custodial care needs, etc.
  • Proactive outreach to new, unknown people and following leads to make contact with potential members
  • 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
  • Support the TOC RN CM doing a Warm Handoff of Members to the Longitudinal Care Teams of the market once the TOC interventions have been completed and the member is stable and ready for a less intensive, preventive, chronic level of care.

Requirements for the Role:

  • Experience with patient navigation, management, or any kind of direct service provision
  • A passion for working within the community you are a part of or have been a part of in the past
  • Experience in transitions of care management, both in-person and virtual
  • Demonstrate the ability to affect change and have been effective in helping a member or patient adapt to new habits, or change behaviors
  • You are flexible, team-oriented, and willing to wear many hats
  • Experience in the documenting member action plans, care planning, and care coordination and have excellent writing skills
  • You excel at empathy and human interactions and want to improve the health of individuals and whole communities.
  • You are an independent self-starter and a strategic thinker who is eager to learn, improve, and grow.
  • Experience working with individuals with mental health and substance use diagnoses preferred
  • Training in motivational interviewing, behavioral activation therapy, or problem-solving treatment 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.