Registered Nurse Care Coordinator

Registered Nurse Care Coordinator

#communityhealth #healthcare

About Cityblock Health:

Cityblock Health is a pioneering tech-enabled provider focused on serving communities with intricate health needs, delivering enhanced care right where it is most required, block by block.

Established on the belief that "health is local," our organization is rooted in Brooklyn and supported by Alphabet's Sidewalk Labs alongside some of the leading healthcare investors nationwide.

Our mission centers on enhancing the health of marginalized communities.

Our innovative solutions are tailored specifically for Medicaid and lower-income Medicare beneficiaries, meeting our members in their own environments, offering care through community-based teams and Virtual Care services.

In partnership with local organizations, healthcare providers, and prominent health plans, we are reshaping the healthcare system to prioritize what truly matters to our members.

Utilizing state-of-the-art, custom care delivery technology, we provide personalized primary care, mental health services, and social support to create a significantly improved care experience for every member and community we serve.

As we expand in the coming year, we aim to deliver superior care to a greater number of members and their communities.

To achieve this, we seek individuals who share our belief that everyone deserves quality care tailored to their needs within their community.

Our operations are grounded in the conviction that a diverse community is powerful.

To bridge gaps in care and promote equity in the communities we serve, we must begin by fostering diversity and inclusivity within our own team.

Our collaborative approach is characterized by creativity, teamwork, and shared learning that arises from uniting individuals from varied backgrounds and perspectives.

We are committed to ensuring that every member of the Cityblock team, and every Cityblock member, feels valued and included as part of our community.

Core Values:

• Strive for Understanding
• Commit Fully
• Bring Your Authentic Self
• Embrace Discomfort
• Prioritize Members

Team Overview:

Our model emphasizes field-based, home-centered care, dedicated to meeting members in their homes, communities, and our Hubs.

You will connect with Cityblock members in a compassionate, respectful, and non-judgmental manner, addressing their needs and providing feedback to enhance our system as we continuously improve.

Role Responsibilities:

• Collaborate with members during care transitions, ensuring that established metrics are met, including communication with inpatient facilities and members, as well as conducting home visits post-discharge to confirm provider follow-up and accurate medication reconciliation.
• Ensure members receive the Long-Term Services and Supports (LTSS) they require by providing clinical justifications for LTSS services for assigned members, ensuring they meet the criteria for recommended services and communicating this with LTSCs.
• Evaluate members to provide a precise clinical and holistic representation during their initial and annual assessments (MDS) as necessary.
• Offer clinical assistance for chronic disease management to members based on RN consultation criteria in collaboration with your interdisciplinary care team, prioritizing member visits according to their health requirements.

Support may include:
education on chronic disease management and self-care, guidance on medical equipment, medication reconciliation & administration inquiries, and assessment of clinical concerns.

• Provide clinical consultation for care team members, offering insights on clinical matters, support with care plans, and review of clinically significant member conditions.
• Engage in a transformative healthcare model.
• Track all metrics related to care transitions for assigned members, including logging new transition events and accompanying follow-up metrics.
• Anticipate collaboration, shared decision-making, and partnership across clinical and non-clinical team members, including our extensive team of Community Health Partners.
• Conduct your work both remotely, connecting with members via phone and video visits, as well as meeting members in the community.
• Utilize strong time management skills to make impactful decisions regarding member care while balancing daily team meetings, weekly case discussions, and skill-building workshops.
• Employ our custom-built care facilitation platform, Commons, and the market's EMR to gather data, document member interactions in the field, organize information, track tasks, and communicate with your team, members, and community resources.

Qualifications:

• Active, unrestricted Registered Nurse license in the state of employment with Cityblock.
• Minimum of 3 years of experience providing clinical services or care management to adults with co-occurring chronic medical and behavioral health conditions.
• Full-time availability for a 40-hour work week, Monday to Friday from 9 am to 5 pm, with a rotating Saturday schedule from 9 am to 1 pm.
• Experience and comfort working within an interdisciplinary care team, particularly alongside community health workers and care coordination team members.
• Willingness to travel within your community for home-based member visits and navigate its healthcare systems (hospitals and rehabilitation centers).
• Experience in managing transitions of care, both in-person and virtually.
• Exceptional triage, coordination, and clinical assessment skills.
• Demonstrated proficiency and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy), and care plan reinforcement for common chronic conditions like diabetes, hypertension, CHF, and depression.
• Proven ability to drive change and effectively assist a member or patient in adopting new habits or modifying behaviors.
• Enthusiasm for leveraging technology to enhance your work and contribute to ongoing evaluations toward improved care.
• Technical skills and ability to work with data systems, including Google Sheets.
• Independent self-starter, leader, and strategic thinker excited about the broader picture of community health and the continuous evaluation and refinement of our care model.
• Valid driver's license and vehicle for daily use.
• Bachelor's degree preferred.

Additional Information:

• A resume and/or LinkedIn profile is required.

Cityblock values diversity as a fundamental principle of our work and the communities we serve.

We are an equal opportunity employer, without discrimination based on 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 external recruiters or placement agencies. Cityblock will not cover fees associated with resumes submitted through unsolicited channels.

Medical Clearance (for Member-Facing Roles):

Completion of Cityblock's medical clearance requirements is mandatory, which may include, but is not limited to, proof of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or an approved medical or religious exemption from vaccination against these diseases.

COVID-19 Update:
Cityblock requires proof of COVID-19 vaccination for those hired into this position.

Individuals subject to this requirement may submit a request for exemption based on valid religious or medical reasons, using forms provided by Cityblock.

Such requests will be reviewed and approved by the Company, with exemptions granted only if a reasonable accommodation can be provided in relation to the requested exemption.

Note that approvals for reasonable accommodations are assessed on a case-by-case basis, and availability is not guaranteed.

This vaccination requirement is informed by recently established government mandates and is rooted in the safety and effectiveness of the vaccine in protecting against COVID-19, as well as our collective responsibility for the health and safety of members, colleagues, and the community.

The COVID-19 pandemic has profoundly affected the health and lives of individuals globally, particularly vulnerable populations served by Cityblock.

As a healthcare provider, Cityblock is committed to the highest standards in promoting the health and safety of those we serve.

Given the critical role of COVID-19 vaccines in combating this disease and saving lives, Cityblock is implementing a COVID-19 booster mandate for employees in Washington, D.C., in accordance with local and state guidelines.

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