About 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. 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 and Virtual Care offerings.

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. 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:

• Aim for Understanding
• Be All In
• Bring Your Whole Self
• Lean Into Discomfort
• Put Members First

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 Cityblock members 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:

The Perinatal RNCM manages a panel of high and rising risk perinatal members and their neonates, providing longitudinal care through pregnancy and the postpartum period, ongoing chart review, member guidance, education and care planning, home visiting especially following emergency room and hospital visits, and review of members at regular case conferences. The Perinatal RNCM collaborates with members to create and support progress on care plans, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Perinatal Community Health Partner to build trust, informed by principles of birth equity and reproductive justice.

• Engagement
• • Receives members from engagement/outreach and care team
  • Describe program expectations (e.g., length) and goals to members
• Assess/Intake
• • Complete self-efficacy and relevant condition-specific screeners with members
    • Complete additional tools or screeners as needed, including relevant behavioral health screeners (e.g., PHQ9, GAD-7, AUDIT, DAST-10)
  • Conduct an in-person clinical exam, if appropriate
  • Collaborate with care team members to determine need for member placement in a different program (e.g., lower or higher intensity programs)
• Case Review and Care Planning
• • Prepare for and participate in case conferences with interdisciplinary care team
  • Develop clinical aspects of care plan (Member Action Plan) with the member and interdisciplinary care team, collaborate with Community Health Partner on social needs as needed with attention to cultural resonance and health equity
• Clinical Visits and Follow-Up
• • Regular check-ins with high acuity member as guided by program workflows
  • Follow-up on routine therapeutic interventions by internal or external providers (in collaboration with care team)
  • Address and responds to member needs and delegate tasks in timely fashion
  • Collaborate on a panel of members assigned to your care team to provide clinical support, identify unmet needs, and achieve member goals, including health maintenance, chronic disease management and co-occurring psychiatric disorder support
    • Medication reconciliation, administration, compliance, education and home monitoring
  • Address contracted and company prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure
  • Support members in achieving their care plan goals
• Operations
• • Utilize our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources

Requirements for the Role:

• Graduate of an accredited school of nursing (R.N.)
• Specialty in Pregnancy, Sexual and Reproductive Health
• Active RN License in the state(s) practicing, Unrestricted Driver’s License
• Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)
• Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management
• Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation
• Versed in Motivational Interviewing and Trauma-Informed Care principles
• Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members
• Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members’ care and health
• Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities
• Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities
• Leverage strong time management skills to to make impactful judgment calls on member care and balance with daily team meetings, weekly case conferences, and skill-building workshops

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.

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We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.