Care Team Lead (RN, Registered Nurse) at Cityblock Health
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.
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 Care Team Lead, RN. You will supervise a team of clinically based Community Health Partners & RN Care Managers across markets. This role will work report up to the Director of Care Transitions. You will provide clinical support to a team of virtually based to ensure care coordination, quality care management, positive patient health outcomes, and Transitions of Care support. You will be the people manager for these team members to support the management of their day-to-day. You will work with a small panel of members to improve their health holistically and step in to provide support to your team members as they encounter complex members.
- You will supervise a team of our virtual-based RNs and CHP’s underneath the Director of Care Transitions to ensure success in the current centralized TOC markets(NY, CT, MA, DC, NC).
- You are responsible for ensuring your team provides quality care for Cityblock members through Transitions of Care, chart review, metrics review, and conversations about complex cases.
- You are a subject matter expert in areas of Care Transitions and offer your expertise across the entire TOC team.
- You will work closely with the Senior CHP to manage the team’s daily huddles & and weekly case conferences.
- You will ensure the efficiency and maintenance of the TOC huddle tracker to support pod members for success.
- A Commons and EHR superuser and assist your team in using the tool appropriately and efficiently.
- Provide supervision and leadership for a team of Community Health Partners (CHPs), supporting them in meeting population-level expectations.
- Lead the operations of an interdisciplinary care team, directly coordinating team time for each of the care team members.
- Provide guidance, coaching, and training around engagement, care planning, and longitudinal care.
- Support CHPs and RN’s through their member outreach and engagement efforts.
- Hold RN & CHPs accountable for completing a comprehensive assessment of members’ health needs, including physical, behavioral, and social.
- From that assessment, support the development of member-driven, member-centered action plans that address social needs.
- Model how to foster lasting and trusting relationships by doing so with your team and your members.
- Act as a point person for the members on your team’s panels; co-visit members with CHPs, provide assistance in crises, etc.
- Support your team to work with members longitudinally to achieve their goals and identify new needs.
- Work daily within our custom-built care facilitation platform, Commons, which will enable you to collect data, organize information, track tasks, and communicate with staff, patients, and family. This platform is built for a mobile workforce, and you will field-test our technology, provide feedback to the product development team, and, over time, become part of a super-user group to assist in onboarding and supporting others.
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 leading 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 judgment 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 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
- A 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.