Registered Nurse (RN)- Care Manager (Spanish Required)
Company: Cityblock Health
Location: Bronx
Posted on: May 14, 2022
Job Description:
#communityhealth #healthcareAbout Us: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
- Aim For Understanding
- Lean Into DiscomfortAbout 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 resourcesRequirements 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 ariseHow 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 targetsNice 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
- Multilingual
- Bachelor's degree preferredWhat 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.Locations:
Cityblock is not hiring for this position in the state of
Colorado.
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.
The COVID-19 pandemic has severely impacted the health and lives of
people around the world, including the vulnerable populations
Cityblock serves. As a healthcare provider, Cityblock holds
ourselves to the highest standards when promoting the health and
safety of those who we serve. Given that the COVID-19 vaccines are
one of the most powerful tools to fight this disease and save
lives, Cityblock is implementing a COVID-19 booster mandate for
Washington, D.C. employees under the guidance of local/state
mandates.
Keywords: Cityblock Health, New Rochelle , Registered Nurse (RN)- Care Manager (Spanish Required), Executive , Bronx, New York
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