Facebook pixel

Transitions of Care Resource RN
MA, Essex County
Posted on 12/15/2022
Essex County, MA, USA
Experience Level
  • A resume and/or LinkedIn profile
  • A short cover letter, please!
  • Co-manage members during transitions of care, ensuring outlined metrics are achieved including contact with inpatient facilities and members, as well as home visits post discharge to ensure provider follow up and accurate medication reconciliation is performed
  • Ensure member's have the LTSS services that are clinically needed by providing supporting clinical justifications for LTSS services for assigned members ensuring they meet criteria for suggested services and communicate this information with LTSCs
  • Assess members to provide accurate clinical and holistic depiction of the member at their Initial and annual assessments (MDS) as needed
  • Provide clinical support for chronic disease management to members based on RN clinical consultation criteria in conjunction with your interdisciplinary care team, prioritizing member visits based on their health needs. This support may include: health education regarding chronic disease processes and self management, teaching related to medical equipment, medication reconciliation & administration questions, assessment of clinical issues
  • Provide clinical consultation for care team members including information on clinical issues, support with care plans and review of clinically concerning member conditions
  • You will work in a radically different model of healthcare
  • Manage the tracking of all metrics related to transitions of care for assigned members including logging new TOC events and accompanying follow up metrics
  • Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners
  • Your work will be completed both remotely with connection to members via telephone and video visits as well as meeting members in the community
  • 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
  • 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
  • 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 or care management to adult individuals with co-occurring chronic medical and behavioral health conditions
  • Work a full-time 40 hour week, Monday-Friday 9am to 5pm with a rotating Saturday 9am - 1pm
  • 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
  • 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
  • Possess technical skills, ability to work with google sheets, and other data systems
  • 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
  • An unrestricted driver's license and vehicle for daily use
Cityblock Health

201-500 employees

Tech-driven healthcare provider
Company Overview
Cityblock's mission is to improve the health of underserved communities by creating solutions that are designed specifically for Medicaid and lower-income Medicare beneficiaries. The company delivers 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.
  • Comprehensive health, dental, & vision coverage
  • 12 weeks parental leave
  • 401(k)
  • 20 days vacation
  • Company retreats & events
Company Core Values
  • Put members first
  • Aim for understanding
  • Be all in