RN Care Manager at Cityblock Health
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.
- 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:
As the RN Lead- Community, you will report to the Manager/Director, Nursing & Community. You will supervise a team of community-based RN Care Managers across one market. You will provide clinical support to our team of community-based RNCM to ensure care coordination, quality care management, and positive patient health outcomes. You will work with a small panel of members to improve their health holistically.
- You will supervise a team of our community-based RNs (TOC Team and Assessment RN Team) underneath the Manager/Director of Nursing to ensure success in our DC market.
- You are responsible for ensuring your team provides quality care for Cityblock members through chart review, metrics review, and conversations about complex cases.
- You are a subject matter expert in areas of care and offer your expertise across the entire RNCM team.
- You will be apart of design, implementation and roll out of RN related workflows
- You are sought after for your partnership liaising between the Care Team Lead Manager and Outreach Specialist Manager.
- A Commons and EHR super user and assist your team in using the tool appropriately and efficiently.
- A leader in your team and the liaison for support, you help to drive positive culture, morale, and model cityblock values.
- Supervises daily activities of NCMs in the assigned Pod to ensure delivery of quality care and care management to all members.
- Participate in coordination of care for LTSS members
- Provide training to new hire NCM
- New Nurse onboarding
- Reviews of all the technology (eg slack, google suite, great expectations, epic onboarding, escalations)
- Sending out welcome emails
- Scheduling meet & greet
- Shadowing schedule & transition into their pod
- New Nurse onboarding
- Teach & provide continued support of documentation guidelines
- Enforcing consistency and appropriate documentation
- Provide teaching for creating smart MAP goals as an NCM
- Monitor/Evaluate NCMs MAP goal maintenance
- Review metrics & performance on a weekly basis with assigned NCM
- Provide feedback & support
- Assist with Panel and time management
- Participating in management, departmental and interdepartmental meetings, and community partners as required
- Responsible for assisting the Nursing Manager with changes in policy or procedures for NCMs
- Provides input on nursing practices, roles, and responsibilities
- Market-wide interdisciplinary training for clinical policies and procedures
- Coordination, planning, and leading RN Staff Meetings
- Leadership for strategy development and implementation readmission reduction
- Office Hours
- Held bi-weekly
Requirements for the Role:
- Active, unrestricted Registered Nurse license in the state in which you are seeking employment with Cityblock. BSN required, MSN strongly preferred.
- You have 5+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions
- 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, 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 adopt 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
How We Define Success:
- Effectively manage your team, coaching, providing feedback, helping them unstick roadblocks to successfully care for members.
- Strong, consistent and reliable communication with direct reports, management team, members and colleagues.
- Consistent use of critical thinking skills and excellent clinical judgement to manage complex clinical issues leveraging assessment skills and protocols.
- Ensure that all member’s medications are accurate and follow prescriber’s orders
- Participate in assessing the quarterly targets set (i.e. are they the right things to measure for member care?)
- Lead through accountability to Cityblock’s members and your team.
Nice to Have, But Not Required:
- Experience caring for members in a low-income community or in a community health setting
- Experience in caring for individuals with complex acute/chronic diagnosis
- Experience in a Nursing supervisory role in their previous tenure
- Experience caring for individuals experiencing homelessness
- Experiencing caring for individuals with criminal justice involvement
- Experience in hospice, acute care, and/or care management
- Trauma-informed approach to clinical care
- Training in Motivational Interviewing
- CCM( Certified Case Manager)
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.
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