Who we are:

At Cityblock Health, our mission is to radically improve the health of urban communities, block by block. We integrate services to address physical, behavioral, and social needs together, delivered at community hubs and through field-based care teams to make healthcare more accessible, supportive and goal-driven for the people who need it most.

 Every aspect of the Cityblock care model is carefully designed to focus on our members, engaging and empowering them to own and improve their health through trusted relationships. Through mobile interdisciplinary care teams, we are flexible in how we deliver care, meeting members where they are, and together developing and working longitudinally through a personalized and integrated Member Action Plan (MAP). The care team collaborates to support each member’s whole health and social needs. Enabled by custom-built technology, we build capacity, deliver care and dramatically change members’ opportunities and outcomes.

Partnering with community-based organizations and a well-respected commercial partner in New York, and backed by the top healthcare investors in the country, we are reorganizing the health system to focus on what matters to our members—and leading the move from transactional, fee-for-service medicine towards high-value, relationship-based partnerships.

The role:

In this role, you will be part of the team at our founding clinical “Hub”, a primary care practice that in many respects looks and feels more like a community center than a doctor’s office, providing direct services to members, who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. At our core, our care model is focused on meeting people where they are, both physically and emotionally. Given this, your work will frequently take you out into the field and surrounding community to support the care in settings that work best for our members.

As the RN Manager, you will provide clinical and managerial support to the RN team. You will support our RN team in providing holistic care and supporting our members when they leave the hospital, receive new diagnoses, are preparing for a procedure, are managing their chronic illnesses, are in pain, or when they need additional education. You will ensure appropriate and timely documentation of notes, completion of assessments and member actions plans, regular visits, appropriate follow-up after transitions, and high quality and trauma informed clinical care. You will also support their personal and professional training and development. You will help drive and shape the delivery of the care model and help bridge the clinical, social, and behavioral health care models while modeling effective team work.

You will:

• Supervise the RN team both clinically, managerially, and administratively
• Perform 1 on 1s, case, and chart reviews to ensure clinical quality
• Help interview and grow the RN team
• Ensure ongoing professional and clinical learning and development for the team
• Lead clinical learning initiatives throughout the hub
• Along with the rest of the clinical health team, develop programming and new initiatives based on member needs (i.e. support groups, educational sessions, co-location initiatives, new partnerships with local community agencies, presence at community events, etc.)
• Coordinate services and relevant Member Action Plan (MAP) goals and tasks with Cityblock care teams, as well as community service providers
• Provide ongoing care team support from a behavioral health perspective
• Foster lasting and trusting relationships; act as the point person for the members on your panel
• Partner with members in their homes, communities, and through the complicated paths of the healthcare system. Work with them longitudinally to achieve their goals and identify new needs
• Go above and beyond to connect with people 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
• Work daily within our custom-built care facilitation platform, which will enable you to collect data, organize information, track tasks, and communicate with staff, patients, and family. This platform is being built for a mobile workforce, and you will be among the first cohort to 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
• Participate in a rotating schedule of weekend and holiday coverage
• Model effective leadership

You’d be a good fit if:

• You have a current, unrestricted NYS RN license
• You have 5+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions
• 3+ years directly managing a team of RNs (or higher clinical training)
• Willing to work a full-time with Saturday Rotation
• Familiarity and willing to travel within Brooklyn neighborhoods (home-based member visits) and it’s 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
• 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

Nice to have:

• Experience working collaboratively with a interdisciplinary care team, and specifically working alongside community health workers or care coordination staff.
• Management experience in an Ambulatory care setting
• Experience in homecare, hospice, acute care, and/or care management.
• Multi-lingual (Spanish, French Creole)
• Unrestricted NYS Driver’s License and Car

Cityblock values diversity as a core tenet of the work we do and 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.