RN Care Manager

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:

• You will work in a radically different model of healthcare
• Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners
• In addition to supporting your members in the community, you will be asked to support clinical operations in the hub on a rotating basis by having an in-person presence and working with providers as needed
• Co-manage a population living with complex medical and behavioral health conditions

• Collaborate on a panel of members assigned to your care team to provide nursing clinical support, including transitional care, health maintenance, medication reconciliation & administration, chronic disease management and co-occurring psychiatric disorders
• Your work will take you into the community. You will meet with members in their homes, neighborhoods, at the point of hospital discharge and within the healthcare system. These visits can be done individually, or as co-visits with one of your care team members (i.e. Community Health Partners, Behavioral Health Specialists, Nurse Practitioners)
• Conduct several home visits in a given day, including scheduled and unscheduled episodic urgent member needs
• Provide ongoing clinical support to your panel of members in partnership with your interdisciplinary care team, prioritizing member visits based on their health needs
• Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
• Assist members with medication reconciliation, medication administration & medication compliance
• 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
• Foster lasting and trusting relationships to assist members in achieving goals, identifying new needs, and coordinating care
• 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 to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions
• Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with one late evening a week, consisting of team meetings, case conference, supervision, and field-based independent clinical and co-visits.
• 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
• Experience as an active participant in continuous quality improvement projects within a provider setting
• 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
• 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
• You will also participate in a regular Saturday Rotation and the Cityblock on-call schedule. Your work may take you outside of normal business hours as urgent member needs arise
• You have an unrestricted driver’s license and vehicle for daily use

What We’d Like From You:

• A resume and/or LinkedIn profile
• A short cover letter, please!

Job Type: Full-time

Pay: $79,000.00 - $87,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Free parking
• Health insurance
• Mileage reimbursement
• Paid time off
• Referral program
• Travel reimbursement
• Vision insurance

Medical Specialty:

• Home Health
• Primary Care

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Nursing: 1 year (Preferred)
• Case management: 1 year (Preferred)

License/Certification:

• RN (Preferred)

Willingness to travel:

• 25% (Preferred)

Work Location: Remote