Transitions of Care Resource RN

Cityblock Health

Cityblock Health

Suffolk County, MA, USA
Posted on Thursday, September 14, 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:

  • Co-manage members during transitions of care, ensuring outlined metrics are achieved including contact with inpatient facilities and members, as well as home visits post discharge to ensure provider follow up and accurate medication reconciliation is performed.
  • Ensure member’s have the LTSS services that are clinically needed by providing supporting clinical justifications for LTSS services for assigned members ensuring they meet criteria for suggested services and communicate this information with LTSCs.

Assess members to provide accurate clinical and holistic depiction of the member at their Initial and annual assessments (MDS) as needed.

  • Provide clinical support for chronic disease management to members based on RN clinical consultation criteria in conjunction with your interdisciplinary care team, prioritizing member visits based on their health needs. This support may include: health education regarding chronic disease processes and self management, teaching related to medical equipment, medication reconciliation & administration questions, assessment of clinical issues
  • Provide clinical consultation for care team members including information on clinical issues, support with care plans and review of clinically concerning member conditions.
  • You will work in a radically different model of healthcare
  • Manage the tracking of all metrics related to transitions of care for assigned members including logging new TOC events and accompanying follow up metrics.
  • Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners
  • Your work will be completed both remotely with connection to members via telephone and video visits as well as meeting members in the community.
  • 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
  • You have 3+ years of experience providing clinical services or care management to adult individuals with co-occurring chronic medical and behavioral health conditions
  • Work a full-time 40 hour week, Monday-Friday 9am to 5pm with a rotating Saturday 9am - 1pm
  • Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and care coordination team members
  • Familiarity and willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals and rehab centers)
  • Experience in transitions of care management, both in-person and virtual
  • 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 chronic conditions such as diabetes, hypertension, CHF, 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 and better care
  • Possess technical skills, ability to work with google sheets, and other data systems
  • 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
  • An unrestricted driver’s license and vehicle for daily use
  • Bachelor’s degree 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.

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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.