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Manager – Nursing
Transitions of Care, NC
Confirmed live in the last 24 hours
Research Triangle, Durham, NC, USA
Experience Level
Desired Skills
  • A resume and/or LinkedIn profile
  • A short cover letter, please!
  • Supervise and Manage a team of RNs and Community Health Partners (CHPs), Behavioral Health (BH) Case Managers, BH CHPs, and other market-specific roles that support TOC operations (that could also include TOC medical Assistants, CTOAs, etc)
  • Responsible for ensuring that the TOC model (and interventions) are executed as intended, ensuring evidenced-based interventions result in better member health and social outcomes and are aligned with the member's values and preferences
  • Responsible for the implementation of TOC interventions in accordance with existing federal, state, local and payor standards and compliance requirements
  • Ensure clinical and operational KPIs are met, resulting in reduced readmission, ED utilization and overall reduction of total cost of care
  • Oversight of education for medical CMS criteria for members when entering the hospital, post-acute care facilities and/or community-based medical needs
  • Provide education to physicians, case managers and other team members on issues related to utilization review; including inappropriate admissions and placements
  • Work closely with the Senior CHPs and Senior RNs to manage the team's daily huddles and weekly case conferences
  • Ensure the efficiency and maintenance of the TOC huddle tracker to support members as they transition through health care settings
  • Assist your team in using the Case Management Platform and Electronic Health Record systems
  • Supervise the completion of comprehensive assessments of members' health needs, including physical, behavioral, and social
  • Educate and ensure the development of appropriate member-centered care plans with SMART goals and weekly interventions in the modality appropriate for the member's risk
  • Responsible for providing assistance in complex cases and escalating events for members with urgent needs
  • Works daily within the Care Management platform to collect data, organize information, track tasks, and communicate with staff, patients, and family
  • Responsible for providing coaching to the TOC team around engagement, care planning, and longitudinal care. In addition, this role will review individual performance and outcomes metrics
  • Occasionally provide direct care for members undergoing a TOC event (likely in the event of opportunities for training and coaching or any other situation that will ensure appropriate functioning of the TOC team at all times)
  • Current, unrestricted RN license in the state of practice and ability to obtain additional licensure if required
  • 5+ years of clinical experience in an acute care, home health, hospice, geriatric and/or hospital setting
  • 3+ years directly managing a team of RNs (or higher clinical training)
  • CCM certification preferred
  • Experience using EMR and CM practice guidelines
  • Experience leading the day-to-day operations of interdisciplinary teams
  • Knowledge of discharge planning alternatives options and interdisciplinary approaches
  • Possess exceptional triage, coordination and clinical assessment skills
  • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
  • 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
  • Familiarity and willing to travel within the community (home-based member visits) and its healthcare systems (hospitals and rehab centers)
  • Access to reliable transportation that will enable you to travel to client and/or patient sites within the assigned care area
  • Experience as an active participant in continuous quality improvement projects within a provider setting
  • Experience working with special needs plans and/or Medicare Accountable Care Organization preferred
  • Knowledge of Medicare and Medicaid benefit products including applicable state regulations preferred
  • Experience with CMS, URAC and NCQA preferred
  • Bilingual (English/Spanish) 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