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Community Health Partner
Transitions of Care, Cincinnati
Confirmed live in the last 24 hours
Cincinnati, OH, USA
Experience Level
Desired Skills
  • A resume and/or LinkedIn profile
  • A short cover letter, please!
  • Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including in partnership with the TOC RN CM
  • Support our members during their time of increased need and is accountable for developing (in collaboration with the TOC RN CM), implementing, and evaluating comprehensive TOC interventions that are evidenced-based but aligned with the member's values and preferences
  • To follow a panel of members who have had a recent transition of care episode, coordinate all aspects of their care through in-person, telephonic or video interventions
  • Engage patients in person, virtually and/or telephonically in different settings, specially in the hospital setting and at home, depending on the patient risk assessment, needs and market preference based on the population served
  • Assist health care staff (in the ED, inpatient setting, post-acute and community settings), under the guidance of the TOC RN CM, in creating the discharge plan that will address identified needs and barriers to support a smooth recovery; assess if the member can be discharged
  • Support the TOC RN CM to perform a post-discharge home visit, and ensure follow-up with a post discharge provider and other providers
  • Attend daily TOC inpatient clinical rounds prepared to assist the TOC RN Care Manager to present admissions, discharges and complex members
  • Coordinate care for members, identifying and addressing their barriers to and social influences on good health. Responsible for implementing specific readmission prevention activities targeting Social Determinants of Health that may be driving hospital utilization, in collaboration with the TOC team. These include and not limited to: housing and food security, transportation, medication access and affordability, caregiving and custodial care needs, etc
  • Proactive outreach to new, unknown people and following leads to make contact with potential members
  • 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
  • Support the TOC RN CM doing 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
  • Experience with patient navigation, management, or any kind of direct service provision
  • A passion for working within the community you are a part of or have been a part of in the past
  • Experience in transitions of care management, both in-person and virtual
  • Demonstrate the ability to affect change and have been effective in helping a member or patient adapt to new habits, or change behaviors
  • You are flexible, team-oriented, and willing to wear many hats
  • Experience in the documenting member action plans, care planning, and care coordination and have excellent writing skills
  • You excel at empathy and human interactions and want to improve the health of individuals and whole communities
  • You are an independent self-starter and a strategic thinker who is eager to learn, improve, and grow
  • Experience working with individuals with mental health and substance use diagnoses preferred
  • Training in motivational interviewing, behavioral activation therapy, or problem-solving treatment preferred
Cityblock Health

201-500 employees

Tech-driven healthcare provider
  • 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