Transitions of Care RN

Cityblock Health

Cityblock Health

Worcester, MA, USA
Posted on Tuesday, November 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:

The Resource RN provides nursing support to the care team, serving as a bridge between the care management team, hub-based clinical team and members. The Resource RN is available to support and consult on member-specific needs (e.g., in-person visits, clinical education, targeted clinical interventions), and is home based, meaning days will primarily be virtual, but can go into the field on occasion. The Resource RN does not carry a panel, however the RN may work lists of members for targeted clinical reasons.


  • Support Member Navigator in ensuring assessments are correctly interpreted and triaged

Case Review and Care Planning

  • Collaborate with care team members to sign-off on care plans, determine need for escalation and to help problem solve care plan barriers
  • Serve as clinical resource for team members, assisting with clinical goals, education and acute clinical needs

Clinical Visits, Practices & Procedures

  • Medication reconciliation, administration, compliance, and education; medication refills per standing protocol or provider order
  • Ability to meet with members in their community (home, SNF, shelter, hospital), primarily as an extender of the care team providers (e.g., APC, MD/DO, RN, pharmacist).
    • Provider extension may include: Injections, vitals checks/monitoring, “eyes in the home” type global assessment of member status, minor procedures, in-home medication reconciliation (including pill box organizing and pill counts)
    • RN Care Manager extension may include: Preventative health screening tools, DME measurement/fit, coordination and education (e.g., setting up glucometer, etc.), in-home disease management education, wound assessment and care, blood drawing (venipuncture and phlebotomy), assessment and care plan reinforcement for chronic conditions (e.g., diabetes, hypertension, CHF, depression)
  • 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
  • Ensure members have the long term services and support (LTSS) that are clinically needed - provide supporting clinical justifications for LTSS services to ensure members meet criteria for suggested services and communicate this information with the appropriate stakeholders.
  • Provide care team support from a nursing perspective, and act as a bridge between on-site and field-based care


  • Hand-off members to longitudinal care team for continued follow-up
  • Address and respond to member needs and delegate tasks in timely fashion
  • Available for referrals to triage needs and provide clinical education
  • Support members in achieving their care plan goals

Clinical Education and Training

  • Schedule shadowing/field training for all new RN care managers
  • Provide training related to medical equipment and provide continuing education for chronic disease management to those with less intensive training (e.g., Medical Assistants, Community Health Partners)

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

Requirements for the Role:

  • Graduate of an accredited school of nursing (R.N.)
  • 3+ years of experience
  • Active RN License in the state(s) practicing Unrestricted Driver's License
  • 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
  • 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.