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Register Nurse
Rn, Transitions of Care, OH, Cin
Posted on 11/15/2022
Cincinnati, OH, USA
Experience Level
Desired Skills
  • A resume and/or LinkedIn profile
  • A short cover letter, please!
  • Support our members during their time of increased need and is accountable for developing, implementing, and evaluating comprehensive TOC interventions that are evidenced-based but aligned with the member's values and preferences (member centric)
  • Responsible for the implementation of TOC interventions in accordance with existing federal, state, local and payor standards and compliance requirements
  • You will be expected to engage patients in person, virtually and/or telephonically in different settings, specially in the hospital setting and at home, depending on the patient needs and risk assessment
  • Provides assistance to patients, families, and/or significant others and facilitates assistance when Social Determinants of Health impact the recovery process and may pose a risk for readmission and ED utilization
  • Assess the member's knowledge of their clinical condition and provide education and self-management guidance based on the member's unique learning style
  • Responsible for implementing specific readmission prevention activities in collaboration (including delegation of tasks) with the TOC team
  • Responsible for applying medical necessity CMS criteria to patients entering the hospital and post acute care facilities
  • Provide education to physicians, case managers and other members of the team on the issues related to utilization review including inappropriate admissions and placements
  • Act as a patient advocate by negotiating for, and coordinating resources with payers, agencies and vendors as appropriate
  • Responsible for collecting patient clinical and demographic data, document appropriately, educating the patient and family on disease management strategies, and arrange for post-discharge support services
  • Your work will take you into the community (depending on market specific needs). You will meet with members in their homes, and 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 TOC care team members (i.e. Community Health Partners, Behavioral Health Specialists, Nurse Practitioners)
  • Assist hospital staff in creating the discharge plan that will address identified needs and barriers to support a smooth recovery; assess if the member can be discharged. Confirm Consent with the member every step of the way
  • Once the member is discharged, the TOC RNCM is expected to engage the member immediately post discharge telephonically, perform a home visit, and ensure follow up with a post discharge provider
  • 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
  • In collaboration with an interdisciplinary team and the member, the person will develop a care plan with SMART goals and weekly interventions for 4 weeks in the modality appropriate for the member's risk (phone, virtual or telephonic)
  • Engage the member and medical staff during an ED event, provide the clinical staff with prior medical and social information relevant to the event (if applicable), provide support/resources to transition the patient home safely and coordinate follow up with the member's PCP
  • The RNCM will do a Warm Handoff of Members to the Longitudinal Care Teams of the market once the TOC interventions have been completed and the member is stable and ready for a less intensive, preventive, chronic level of care
  • Current, unrestricted RN license in the state of practice and ability to obtain additional licensure if required
  • 3+ years of clinical experience in an acute care, home health, hospice, geriatric and/or hospital setting
  • 2+ years of case management experience preferred
  • CCM certification preferred
  • Experience using EMR and CM practice guidelines
  • Knowledge of discharge planning alternatives options and interdisciplinary approaches
  • Access to reliable transportation that will enable you to travel to client and/or patient sites within the assigned care area
  • Independent problem identification/resolution and decision making skills
  • Bilingual (English/Spanish) proficiency preferred
  • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
  • Knowledge and experience with CMS, URAC and NCQA preferred
  • Knowledge of Medicare and Medicaid benefit products including applicable state regulations preferred
  • Experience working with individuals with multiple co-morbidities and complex medical conditions preferred
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