Transition of Care RN (Mobile Integrated Care) at Cityblock Health

| Greater NYC Area
Sorry, this job was removed at 7:17 a.m. (EST) on Thursday, December 9, 2021
Find out who's hiring in NYC.
See all HR + Recruiting jobs in NYC
Apply Now
By clicking continue you agree to Built In’s Privacy Policy and Terms of Use.

#communityhealth #healthcare

About Us:

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.

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:

As a Transitions of Care RN, you will coordinate with the member, their case manager, and the internal Cityblock care teams to ensure a safe transition from the health care setting to their home, and that they do not return to the hospital. This includes connecting with the member at the healthcare setting, connecting with the member in their home, and ensuring the member has what they need to be able to stay safe and at home.

More specifically, you will be part of a new Transitions of Care team led by the Director of Care Transitions that will be accountable for managing the post-discharge and readmissions processed in all of Cityblock Markets. This team will manage members post-discharge for a 30-day period and respond in real-time to readmissions that occur. 

  • You will work in a radically different model of healthcare
  • Expect collaboration, shared making, and partnership across clinical and non-clinical care team members, including in partnership with the Readmissions RN.
  • You will maintain a fluctuating panel shared with the Readmissions RN of anywhere between 30-250 members as they cycle through the 30-day post-discharge period, depending on the volume of admissions and readmissions 
  • Own the end-to-end readmission prevention process post-admission; this includes, but is not limited to: 
    • Identify:
      • Monitor our internal HIE alert system to quickly outreach to members admitted or readmitted to the hospital or facility
    • Assess:
      • Telephonic and in-person outreach to the member and their case managers post-hospitalization, ER visit, or Skilled Nursing stay to conduct a comprehensive assessment that includes medical, behavioral, pharmaceutical, and social needs to improve health and reduce the risk of readmission
    • Engage:
      • Assist hospital staff in creating the discharge plan that will address identified needs and barriers to support a smooth recovery; assess if the member can be discharged. Confirm Consent with the member every step of the way
    • Timely Contact Post Discharge:
      • Assess the member’s knowledge of their clinical condition and provide education and self-management guidance based on the member’s unique learning style
      • Conduct virtual in-home visits or dispatch our Community Rapid Response team to assess safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
    • Proactive Mitigation:
      • Weekly follow up by the Readmissions Reduction Team with the member consistently for 30 days post-discharge to prevent readmission
      • Ensure that the member successfully has a visit with either their PCP or a Cityblock provider post-discharge
      • Coordinate care by serving as the member’s advocate with our internal care teams, the attending physician and case manager, and the member’s family
    • Return to ED Outreach:
      • Respond to return to ED HIE ping within a timely manner in attempts to avoid admission
    • Warm Handoff of Members to Long-Term Cityblock Care Team:
      • Within the 30-day post d/c period fully enroll members to Cityblock Health
  • Comfortable reaching out to new unknown people and following leads to make contact with members
  • Leverage strong time management skills to make impactful judgment calls on member care and balance with daily team meetings and skill-building workshops 
  • 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:

  • You have experience with patient navigation, management, or any kind of direct service provision
  • You have a passion for working within the community you are a part of or have been a part of in the past
  • Hold a Valid RN License
  • Experience in transitions of care management, both in-person and virtual
  • Demonstrate the ability to affect change, and have been effective in helping a member or patient adopt to new habits, or change behaviors
  • You are flexible, team-oriented, and willing to wear many hats
  • Work a full-time 40 hour week, Monday-Friday 9 am to 5 pm ET
  •  Your work may take you outside of normal business hours as urgent member needs arise
  • You are experienced in the documentation of member action plans, care planning, care coordination and have excellent writing skills 
  • You excel at empathy and human interactions and want to improve the health of individuals and whole communities
  • You are an independent self-starter and a strategic thinker who is eager to learn, improve, and grow
  • You are excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care

How We Define Success:

  • Manage the end-to-end transition of the care process to ensure that the members stay safely at home and do not re-admit into a healthcare setting
  • 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 
  • Engage in target setting for new clinical initiatives and managing those targets 
  • Collaboration with existing care team members 

Nice to Have, But Not Required:

  • Experience working with individuals with mental health and substance use diagnoses.
  • Training in motivational interviewing, behavioral activation therapy, or problem-solving treatment.
  • Direct familiarity with clinical settings.
  • Multilingual

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.
Read Full Job Description
Apply Now
By clicking continue you agree to Built In’s Privacy Policy and Terms of Use.

Technology we use

  • Engineering
  • Product
    • PythonLanguages
    • ScalaLanguages
    • SqlLanguages
    • ReactLibraries
    • Node.jsFrameworks
    • PostgreSQLDatabases
    • Google AnalyticsAnalytics
    • LookerAnalytics
    • IllustratorDesign
    • PhotoshopDesign
    • ConfluenceManagement
    • Google DriveManagement
    • Google DocsManagement
    • Google SlidesManagement
    • JIRAManagement
    • ClickUPManagement

Location

Cityblock is committed to flexible work. Due to the COVID-19 pandemic, most of our business team is operating remotely.

An Insider's view of Cityblock Health

What's something quirky about your company?

There's a slack channel for everything - plants, podcasts, cooking, baking, hiking, Peloton - I love it

Tina

Implementation Manager

How does the company support your career growth?

My manager and I do monthly check-ins on career development during our 1:1s. This has been a great opportunity to address areas I'd like to improve and set up an action plan.

Jose

Senior Software Engineer

What are Cityblock Health Perks + Benefits

Cityblock Health Benefits Overview

To properly care for our members and advance equity in the communities we serve, we believe our own team must be diverse and inclusive. We take to heart what it means to bring your whole self and actively work to build representation, build belonging and advance justice. Our goal is to ensure everyone at Cityblock feels respected, celebrated, and part of our community.

Culture
Volunteer in local community
Partners with Nonprofits
Friends outside of work
Eat lunch together
Intracompany committees
Daily sync
Open door policy
Team owned deliverables
Team based strategic planning
Group brainstorming sessions
Open office floor plan
Diversity
Documented equal pay policy
Dedicated Diversity/Inclusion Staff
Highly diverse management team
Unconscious bias training
Diversity manifesto
Diversity Employee Resource Groups
Hiring Practices that Promote Diversity
Health Insurance & Wellness Benefits
Flexible Spending Account (FSA)
Disability Insurance
Dental Benefits
Vision Benefits
Health Insurance Benefits
Life Insurance
Wellness Programs
Mental Health Benefits
Retirement & Stock Options Benefits
401(K)
Company Equity
Child Care & Parental Leave Benefits
Generous Parental Leave
Flexible Work Schedule
Remote Work Program
Family Medical Leave
Vacation & Time Off Benefits
Generous PTO
Paid Holidays
Paid Sick Days
Perks & Discounts
Casual Dress
Commuter Benefits
Relocation Assistance
Home Office Stipend for Remote Employees
Professional Development Benefits
Lunch and learns
Cross functional training encouraged
Promote from within
Customized development tracks
More Jobs at Cityblock Health75 open jobs
All Jobs
Finance
Data + Analytics
Design + UX
Dev + Engineer
HR + Recruiting
Marketing
Operations
Product
Project Mgmt
Sales
Content
Project Mgmt
new
New York
Sales
new
Remote
Design + UX
new
Remote
Operations
new
New York
HR + Recruiting
new
New York
HR + Recruiting
new
New York
Data + Analytics
new
New York
Data + Analytics
new
New York
Developer
new
New York
Operations
new
New York
Marketing
new
New York
Data + Analytics
new
New York
Finance
new
Remote
Design + UX
new
New York
Project Mgmt
new
New York
Developer
new
New York
Product
new
New York
Project Mgmt
new
New York
Operations
new
Remote
Developer
new
New York
Developer
new
New York
Data + Analytics
new
New York
Developer
new
New York
Developer
new
New York
Data + Analytics
new
New York
Data + Analytics
new
New York
Finance
new
New York
HR + Recruiting
new
New York
Operations
new
New York
Operations
new
New York
Operations
new
New York
Project Mgmt
new
New York
Operations
new
New York
Developer
new
Remote
HR + Recruiting
new
Remote
Developer
new
Remote
Data + Analytics
new
Remote
Data + Analytics
new
New York
Marketing
new
Remote
Data + Analytics
new
New York
Marketing
new
Remote
Design + UX
new
New York
Marketing
new
New York
Product
new
New York
Operations
new
New York
Data + Analytics
new
New York
Operations
new
New York
Operations
new
New York
Data + Analytics
new
New York
Apply Now
By clicking continue you agree to Built In’s Privacy Policy and Terms of Use.
Save jobView Cityblock Health's full profileSee more Cityblock Health jobs