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Registered Nurse (RN)- Care Manager

Company: Cityblock Health
Location: New York
Posted on: April 10, 2021

Job Description:

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, one block at a time. 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. 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. We will get started in new markets, each with their own operating structure and care teams, and continue to grow in the communities where we are working already. 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:--

  • Put Members First
  • Bring Your Whole Self
  • Be All In 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 members in the Brooklyn & Queens communities-- 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:--
    • You will work in a radically different model of healthcare
    • Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners
    • Co-manage a population living with complex medical and behavioral health conditions--
    • Collaborate on a panel of members assigned to your care team to provide, nursing clinical support, including transitional care, health maintenance, medication reconciliation & administration, chronic disease management and co-occurring psychiatric disorders
    • Your work will take you into the community. You will meet with members in their homes, neighborhoods, at the point of hospital discharge and within the healthcare system. These visits can be done individually, or as co-visits with one of your care team members (i.e. Community Health Partners, Behavioral Health Specialists, Nurse Practitioners)
    • Conduct several home visits in a given day, including scheduled and unscheduled episodic urgent member needs--
    • Provide ongoing clinical support to your panel of members in partnership with your interdisciplinary care team, prioritizing member visits based on their health needs
    • Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
    • Assist members with medication reconciliation, medication administration & medication compliance
    • Leverage strong time management skills to to make impactful judgement calls on member care and balance with daily team meetings, weekly case conferences, and skill-building workshops--
    • Foster lasting and trusting relationships to assist members in achieving goals, identifying new needs, and coordinating care
    • 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:
      • Active, unrestricted Registered Nurse license in the state in which you are seeking employment with Cityblock--
      • You have 3+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions
      • Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with one late evening a week, consisting of team meetings, case conference, supervision, and field-based independent clinical and co-visits.
      • Experience and comfort working within 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, blood drawing (venipuncture & phlebotomy), 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 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 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:
        • Co-manage a panel of members to address their long and short-term health needs, ultimately to prevent avoidable hospital and ED visits--
        • Ensure members on your panel:
          • Meet all appropriate preventive care, behavioral health, and burden of disease quality measures--
          • Have accurate health care plans (MAP) with Cityblock--
          • Receive appropriate care following ED visits and acute admissions
          • 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--
          • Ensure that all member' s medications are accurate and follow prescriber's orders--
          • Engage in target setting for new clinical initiatives and managing those targets-- Nice to Have, But Not Required:--
            • Experience caring for members in a low-income community or in a community health setting--
            • Experience caring for individuals experiencing homelessness
            • Experiencing caring for individuals with criminal justice involvement
            • Experience in hospice, acute care, and/or care management 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. How did you hear about this job opportunity? --*
                LinkedIn Profile
                Please select all New York locations you are interested in being considered for: --*
                East New York, Brooklyn
                Crown Heights, Brooklyn
                Queens
                Nassau County
                Are you able to work Full Time, 5 days a week --*
                Have you worked for Cityblock, or received an offer in the past? --*
                This question will help us to filter in-bound candidates who have worked for Cityblock before, or may have received an offer.-- Are you legally authorized to work for Cityblock in the United States? --*
                Will you now or in the future require Cityblock to serve as a sponsor for employment (e.g., H-1B--visa--status)? --*
                Confidential Diversity & Inclusion Survey We take equal opportunity seriously here at Cityblock and are working to build a company that is as diverse as the communities we serve. Completing this survey is voluntary , but we hope that you will choose to answer. All responses are kept completely private - they cannot be seen by anyone reviewing your application, they are not used for or against your candidacy in any way.Because the EEOC identifying questions are limiting, we would like to provide more options to our candidates to self identify for their gender, race, and age. Our work here at Cityblock 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 building a diverse and inclusive team. 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.-- Individuals seeking employment here at Cityblock are considered without regard to race, color, religion, national origin, age, sex, marital status, ancestry, physical or mental disability, veteran status, gender identity, or sexual orientation. And, because we do business with the government, our recruiting and hiring practices must meet affirmative action and equal employment opportunity standards. Part of this is inviting applicants to self identify, which allows us to comply with federal and state Equal Employment Opportunity/Affirmative Action record keeping, reporting, and other legal requirements. Thank you! Toyin, Iyah and Bay-- Co-Founders, Cityblock Health What age group do you belong in?
                18-20
                20-30
                30-40
                40-50
                50-60
                60+
                What gender group do you identify as?
                Cis-Male
                Cis-Female
                Non Binary
                Trans Woman
                Trans Man
                Other (Open Comment)
                What race do you identify as?
                African-American / Black
                Hispanic / LatinX
                Caucasian / White
                East Asian (including Chinese, Japanese, Korean, and Mongolian)
                Native American/Alaskan Native
                Middle Eastern
                Pacific Islander
                South Asian (including Bangladeshi, Bhutanese, Indian, Nepali, Pakistani, and Sri Lankan)
                Southeast Asian (including Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Thai, and Vietnamese)
                Prefer Not To Answer
                Other (Open Comment)
                U.S. Equal Opportunity Employment Information (Completion is voluntary) Individuals seeking employment at Cityblock Health are considered without regards to race, color, religion, national origin, age, sex, marital status, ancestry, physical or mental disability, veteran status, gender identity, or sexual orientation. You are being given the opportunity to provide the following information in order to help us comply with federal and state Equal Employment Opportunity/Affirmative Action record keeping, reporting, and other legal requirements. Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file. Gender Are you Hispanic/Latino? Race & Ethnicity Definitions If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection. As a government contractor subject to Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categories is as follows: A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability. A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Veteran Status Form CC-305 OMB Control Number 1250-0005 Expires 05/31/2023 Voluntary Self-Identification of DisabilityWhy are you being asked to complete this form? We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp . How do you know if you have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:
                • Autism
                • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
                • Blind or low vision
                • Cancer
                • Cardiovascular or heart disease
                • Celiac disease
                • Cerebral palsy
                • Deaf or hard of hearing
                • Depression or anxiety
                • Diabetes
                • Epilepsy
                • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
                • Intellectual disability
                • Missing limbs or partially missing limbs
                • Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS)
                • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression Disability Status 1 Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp . PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Keywords: Cityblock Health, New York , Registered Nurse (RN)- Care Manager, Healthcare , New York, New York

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