RN Care Manager, Transitions of Care - NC (Triad)

Cityblock Health

Cityblock Health

Customer Service
Piedmont, SC, USA
Posted on Friday, August 18, 2023

#communityhealth #healthcare

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 Transitions of Care (TOC) Nurse Case Manager (RNCM) is a highly specialized and skilled RN, who is primarily responsible for accompanying, coaching, managing and supporting the medical, behavioral and social care needs of our members, both pre-consented or consented, as the member transitions through healthcare settings to their home, ensuring the member has what they need to be able to stay safe and at home.

More specifically, the TOC RNCM will be a part of the Market Transitions of Care team that is accountable for managing members during an ED visit, inpatient stay, post acute facility stay, immediate post-discharge to the member’s home and the following 30 days. They will respond in real-time to any readmissions that occur during this time frame. This person will directly impact and adhere to the readmission rate goals and other KPI’s set by the organization, ensuring better member’s experience, lower morbidity, mortality and hospital utilization, reducing total cost of care.


  • 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.

Requirements for the Role:

  • 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

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.


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

Medical Clearance (for Member-Facing Roles):

You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases.

Covid 19 Update - Please Read:

Cityblock requires those hired into this position to provide proof that they have received the COVID-19 vaccine. Any individuals subject to this requirement may submit for consideration a request to be exempted from the requirement (based on a valid religious or medical reason) on forms to be provided by Cityblock. Such requests will be subject to review and approval by the Company, and exemptions will be granted only if the Company can provide a reasonable accommodation in relation to the requested exemption. Note that approvals for reasonable accommodations are reviewed and approved on a case-by-case basis and availability of a reasonable accommodation is not guaranteed. This vaccination requirement is based, in part, on recently established government requirements. The requirement is also based on the safety and effectiveness of the vaccine in protecting against COVID-19, and our shared responsibility for the health and safety of members, colleagues, and community.

The COVID-19 pandemic has severely impacted the health and lives of people around the world, including the vulnerable populations Cityblock serves. As a healthcare provider, Cityblock holds ourselves to the highest standards when promoting the health and safety of those who we serve. Given that the COVID-19 vaccines are one of the most powerful tools to fight this disease and save lives, Cityblock is implementing a COVID-19 booster mandate for Washington, D.C. employees under the guidance of local/state mandates.