Redpoint

Job Description:

Cityblock’s Transition of Care (TOC) program helps members safely navigate their postdischarge journey from acute care and hospital settings back into the community. As a TOC Care Coordinator,, you will reach out to members to schedule postdischarge visits, provide care coordination and drive engagement to help ensure that members do not return to the hospital. This is a hybrid position. Must be commutable to Springfield, IL and East St Louis, IL.

Responsibilities:

• Receive assignments of members from the TOC team and initiate outreach to members or caregivers to schedule postdischarge visits, clearly explaining the TOC program’s expectations and goals.

• Complete all necessary assessments during the assessment and intake phase according to established protocols and under the guidance of the TOC RNCM.

• Support the TOC RNCM in discharge planning, collaborating to develop comprehensive postdischarge care plans that address needs and barriers to facilitate smooth recovery.

• Assist members in achieving care plan goals by providing relevant resources and coaching on goal completion, with a focus on risk mitigation, a "call us first" approach, provider engagement, and addressing social determinants of health.

• Participate in case conferences upon member discharge to discuss strategies for mitigating 30day readmissions and ensuring seamless handoffs to longitudinal care at the conclusion of the TOC program.

• Conduct weekly follow ups with members to monitor post discharge care plan needs, provide care coordination for benefits, social needs, and external care services, and ensure progress is tracked effectively.

• Provide non clinical education on preventive care topics and respond promptly to member needs, delegating tasks as appropriate.

• Engage with members in various community settings, such as homes, SNFs, IRFs, shelters, and hospitals, extending nonclinical support on behalf of the care team.

• Conduct screenings for emerging needs and refer clinical concerns to the TOC RNCM, collaborating with internal teams such as pharmacy, behavioral health, and the mobile integrated care team to close referral loops.

• Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and maintain effective communication with team members and community resources.

• Track TOC metrics for assigned members, logging new TOC events and follow up metrics to monitor member progress and ensure successful outcomes.

Work Experience:

• At least 1-2 years of experience in community care or care coordination required

Education:

• High school degree

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:

$27/hr - $30/hr

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 Vaccine - Please Read:

Cityblock requires individuals hired into in-person, member-facing positions to provide proof that they have received the COVID-19 vaccine.

The requirement is 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.

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 exemption requests are subject to review by Cityblock on a case-by-case basis and approval is not guaranteed.

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.