Job Description: The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy. PG County Responsibilities: Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals. Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs. Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity. Prepare for and actively participate in case conferences, leading discussions when necessary. Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner. Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly. Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support. Perform medication reconciliation, administration, compliance, and education as part of member care. Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures. Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources. Support members in achieving their care plan goals through coordinated and comprehensive care efforts. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) Active RN License in the state(s) practicing Unrestricted Driver’s License Basic Life Support (BLS) certification is a requirement We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. Medical Clearance (for Member-Facing Roles): You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
Job Description: PG County Cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community. The TOC Registered Nurse Care Manager (RNCM) coordinates with hospital case managers to determine members’ needs and to complete discharge visits (in-home or virtual) with members and providers. The TOC RNCM will also be available for referrals to triage members’ needs and provide clinical education, with the goal of helping ensure that members do not return to the hospital. Responsibilities: Assign members and initiate outreach by contacting hospital case managers to understand each member's unique needs before engaging them in the TOC program. Complete self-efficacy and condition-specific screeners during the assess and intake phase, including behavioral health tools like PHQ-9, GAD-7, AUDIT, or DAST-10, to identify members requiring behavioral health programming. Conduct in-person clinical exams if appropriate and collaborate with care team members to determine if a different intensity program placement is needed. Participate in daily inpatient rounds while members are admitted, followed by post-discharge case conferences to support discharge planning. Collaborate with the TOC Care Coordinator and TOC Behavioral Health Specialist to develop post-discharge care plans addressing needs and barriers, ensuring smooth recovery and effective hand-off to longitudinal care. Perform regular check-ins guided by the TOC program, including post-discharge home visits and weekly follow-ups for four weeks, ensuring provider visits are completed and addressing member needs promptly. Meet members in various community settings such as homes, SNFs, IRFs, shelters, and hospitals, providing support for both clinical and non-clinical needs. Conduct comprehensive medication reconciliation and address contracted and company-prioritized quality gaps, ensuring proper chart documentation and appropriate ICD or CPT coding as evidence of gap closure. Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources. Track TOC-related metrics for assigned members, logging new TOC events and follow-up metrics to monitor progress effectively. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. Medical Clearance (for Member-Facing Roles): You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
Job Description: Baltimore, MD The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy. Responsibilities: Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals. Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs. Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity. Prepare for and actively participate in case conferences, leading discussions when necessary. Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner. Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly. Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support. Perform medication reconciliation, administration, compliance, and education as part of member care. Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures. Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources. Support members in achieving their care plan goals through coordinated and comprehensive care efforts. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. Medical Clearance (for Member-Facing Roles): You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
Job Description: The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy. Responsibilities: Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals. Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs. Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity. Prepare for and actively participate in case conferences, leading discussions when necessary. Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner. Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly. Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support. Perform medication reconciliation, administration, compliance, and education as part of member care. Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures. Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources. Support members in achieving their care plan goals through coordinated and comprehensive care efforts. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. Medical Clearance (for Member-Facing Roles): You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
Job Description: Cityblock delivers integrated primary and acute medical care, behavioral health and social care, powered by relationships and designed to advance equity in access and outcome. By delivering these acute and longitudinal services in-home through a combination of digital and in-person connections, we can allow members to stay at home and out of the hospital. The Advanced Community Care Clinician is pivotal in connecting members to Cityblock services including medical providers and access to all Cityblock services. There are several primary visit types they will be responsible for: ED@home: Acute illness facilitated provider visit Facilitated Visit: Longitudinal care team facilitated provider visit Outreach: Independent visit to find hard to reach members Specimen Collection: Independent visit to obtain tissue samples for the lab. MIC Only Follow-up: Independent visit with a specific set of visit goals Each shift the Advanced Community Care Clinician will begin their day reviewing their equipment, communications, and scheduled visits. They will plan to integrate mandatory training, meetings, and lunch into their day at pre-planned times or in any down time. Before the visit they will review Commons and Athena for any warning or instructions about the visit. Review the need for written consent. Arrive 10 minutes prior to the start of the visit and make member contact. Introduce themself and describe how a visit is conducted Complete required charting and activities prior to bringing the virtual provider on video. Use the Cityblock computer to facilitate a video visit. Carryout any instructions like order or examinations, sometimes on camera and sometimes independently as instructed. Post visit they will complete documentation, process lab work in a centrifuge and decontaminate their equipment. They will then get themselves set for the next visit by restocking and preparing equipment. Their vehicle whether Cityblock owned or personal; will be kept, maintained and used in accordance with company policy. Requirements for the Role: RN licensure in the state of Michigan 2+ years of experience BLS CPR Case management, ER or home health experience preferred Unrestricted driver's license 100% daily travel Physical Requirements Climb stairs with 40 lb pack Walk long distances from parking spot to visit address Kneel, stoop, lean over for extended periods of time Sit and ride in a vehicle for extended periods of time Donning and doffing of PPE Wear a N95 for extended periods of time Good hand eye coordination to perform clinical skills Able to see, hear, and smell to perform physical exams Additional Requirements The work environment is dynamic. At all times member confidentiality will be kept by taking meetings in private and not mixing any home or outside work influences while on company time. We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. Medical Clearance (for Member-Facing Roles): You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
