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RN Care Manager - MA (Bristol)

Company: Cityblock Health
Location: Taunton
Posted on: January 15, 2022

Job Description:

#communityhealth #healthcareAbout Us: #communityhealthCityblock 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.Our Values:

  • 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:
    • 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
    • As a full-time employee, you should aim to spend approximately 20 hours of your time on Direct Patient Care (visits) in order to comply with weekly appointment goals. This should be adjusted based on member need.
    • 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 judgement 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
        How We Define Success:
        • Co-manage a panel of members to address their long and short-term health needs, ultimately to prevent avoidable hospital and ED visits
        • Ensure members on your panel:
          • Meet all appropriate preventive care, behavioral health, and burden of disease quality measures
          • Have accurate health care plans (MAP) with Cityblock
          • Receive appropriate care following ED visits and acute admissions
          • Utilize critical thinking skills and excellent communication skills to manage complex clinical issues leveraging assessment skills and protocols
          • Meet evolving monthly and quarterly targets for visits with Cityblock members, in both clinic and home setting
          • Ensure that all member's medications are accurate and follow prescriber's orders
          • Engage in target setting for new clinical initiatives and managing those targets
            Nice to Have, But Not Required:
            • Experience coordinating multi-disciplinary care for members with multiple complex medical and social conditions
            • Experiencing caring for individuals with criminal justice involvement
            • Experience in hospice, acute care, and/or care management
            • Multilingual
            • Bachelor's degree preferred
            • Experience with Minimum Data Set (MDS-HC) assessments
              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.Covid 19 Update - Please Read:Cityblock requires those hired into this position to provide proof that they have received the COVID-19 vaccine. 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 requests will be subject to review and approval by the Company, and exemptions will be granted only if the Company can provide a reasonable accommodation in relation to the requested exemption. Note that approvals for reasonable accommodations are reviewed and approved on a case-by-case basis and availability of a reasonable accommodation is not guaranteed. This vaccination requirement is based, in part, on recently established government requirements. The requirement is also 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.

Keywords: Cityblock Health, Taunton , RN Care Manager - MA (Bristol), Healthcare , Taunton, Massachusetts

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