(TEMP) Assessment NP - Suffolk 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:
- Assess Adult and Geriatric members to provide accurate clinical and holistic depiction of the member at their Initial and Annual assessments, as well as at any point of care in which the member may have had a change
- Maintain accurate and clear documentation for each assessment including: completing the required assessment forms, providing a verbal and written hand-off to the assigned care manager, making any referrals in a timely manner as well as developing a care plan for the member
- Assess for and refer to any of the following services to meet the member's needs: LTSS, Internal or External referrals, Home Health, Safety DME, etc
- Meet with members in their homes, neighborhoods, our clinic (Hub) and within the healthcare system
- Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
- Work daily within our custom-built care facilitation platform, which will enable you to collect data, organize information, track tasks, and communicate with staff, members, and family. This platform is being built for a mobile workforce, and you will use our technology in the field, provide feedback to the product development team, and, over time, become part of a super-user group to assist in onboarding and supporting others
- Utilize critical thinking skills and excellent communication skills to manage complex clinical issues utilizing assessment skills and protocols
- Leverage strong time management skills to ensure that we are within compliance for assessment and fiscal related deadlines
- Go above and beyond to connect with members and partners 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
- Be able and available for occasional cross coverage with RN Care Managers in times of need
- Be required to rotate to a half day on Saturdays in a regular interval pattern, with additional time off during the week to compensate
Requirements for the Role:
- You have a current, unrestricted Massachusetts NP license
- You have 3+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions
- Experience completing MDS assessments
- Familiarity and willing to travel within Middlesex County neighborhoods (home-based member visits) and its healthcare systems (hospitals and rehab centers)
- Experience as an active participant in continuous quality improvement projects within a provider setting
- Possess exceptional triage, coordination and clinical assessment skills
- Phenomenal communicator; you approach care interactions with warmth and thoughtfulness
- Demonstrated 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
- You can accommodate a full time schedule
- 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 believe deeply in a localized, community-based care model and are compelled by the mission that drives Cityblock Health
- Unrestricted Massachusetts Driver's License and Car
How We Define Success:
- Be able to complete all required assessments within a 24 - 48 hour turnaround time
- Achieve and maintain an assessment return rate of less than 15 %
- Mitigate rating category downgrades and increase rating category upgrades, as appropriate
- Maintain accurate documentation in accordance with compliance expectations
- Make targeted LTSS related recommendations utilizing decisioning tools to provide best care for our members
Nice to Have, But Not Required:
- Experience working collaboratively with an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff.
- Experience in primary care, homecare, hospice, emergency department, and/or care management.
- Multi-lingual (Spanish, French Creole)
- Additional certification in Care Management, Palliative Care, Geriatrics, Wound Care
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.