RN Care Manager

Cityblock Health

Worcester, MA, US
  • Job Type: Full-Time
  • Function: Life Sciences R&D/Engineering
  • Post Date: 05/04/2021
  • Website: cityblock.com
  • Company Address: 55 Washington St, Brooklyn, Brooklyn, NY, 11201, US

About Cityblock Health

Cityblock was founded in 2017 as the first tech-driven provider for communities with complex needs. We deliver better care to where it’s needed most, investing upstream in highly personalized, prevention-oriented health and social care to ultimately drive down costs and improve outcomes. Our tech enables scale by bringing together practical information, coordination, and communication for our members and our care teams.

Job Description

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 through mobile, 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 field-based, 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 Massachusetts, and backed by some of 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. Our members face economic and social challenges in addition to having mental and physical health needs, and our model combines with our technology will support our care team and members in a completely new way.


The role: 

In this role, you will provide direct clinical and care management nursing services to Cityblock members as part of our innovative care model, designed to address the complex health and social challenges of high-risk, high-need populations living in urban neighborhoods. You will practice as both a hub-based and mobile care provider, extending out in the surrounding neighborhood and community.  It is integral to our care model that we meet people where they are, both physically and emotionally. Given this, your work will frequently take you out into the community to provide care in settings that work best for our members, but also allow you to practice in a more traditional ambulatory office setting, as part of the interdisciplinary team.

As an RN Clinical Care Manager, you will work with a panel of members to improve their health holistically.  You will support 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 provide a necessary bridge to specialty care, homecare services, and other facility services. Additionally, you will provide critical clinical support and guidance to our large team of Community Health Partners, who will serve as members’ main point-of-contact and coordinator.  You will work alongside, and will be supported by, a care team associated with each member, whose work is focused around a Member Action Plan (MAP).  

You will:

  • Follow a panel of Adult and Geriatric members to provide nursing clinical support, including transitional care, health maintenance, medication reconciliation, chronic disease management and co-occurring psychiatric disorders
  • Continuous outreach to support building and maintaining  member panels for team
  • 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 
  • Foster lasting and trusting relationships to assist members in achieving goals, identifying new needs, and coordinating care
  • 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 make the most impactful judgement calls as we care for a full panel of members, and juggle competing priorities throughout the day 
  • 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

You’d be a good fit if:

  • You have a current, unrestricted Massachusetts RN license
  • You have 3+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions
  • Familiarity and willing to travel within Worcester 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 as well as participate in on call and Saturday coverage rotation.
  • 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 an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff.
  • Experience in primary care, homecare, hospice, acute care, and/or care management.
  • Multi-lingual (Spanish, French Creole) 
  • Bachelor’s degree preferred
  • Unrestricted Massachusetts Driver’s License and Car
  • Additional certification in Care Management, Palliative Care, Geriatrics, Wound Care

You should include these in your application:

  • A resume and/or LinkedIn profile.
  • A 1-2 paragraph response indicating why this job is compelling to you.
  • A 1 paragraph summary of a time when you thought you made a difference in someone’s health.

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.

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Disclaimer: Local Candidates Only
This company does NOT accept candidates from outside recruiting firms. Agency contacts are not welcome.