Job Description:

About the Role:

Cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community. The TOC Registered Nurse Care Manager (RNCM) coordinates with hospital case managers to determine members’ needs and to complete discharge visits (in-home or virtual) with members and providers. The TOC RNCM will also be available for referrals to triage members’ needs and provide clinical education, with the goal of helping ensure that members do not return to the hospital.

Responsibilities:

Engagement

• Receive assignment of members from TOC manager

• Reach out to hospital case manager to understand member needs

• Reach out to member to engage for TOC program

Assess/Intake

• Complete self-efficacy and relevant condition-specific screeners with members

  • Complete additional tools or screeners as needed, including relevant behavioral health screeners (e.g., PHQ9, GAD-7, AUDIT, DAST-10)

• Triage members with need for behavioral health programming

• Conduct an in-person clinical exam, if appropriate

• Collaborate with care team members to determine need for member placement in a different program (e.g., lower or higher intensity programs)

Case Review and Care Planning

• Participate in daily inpatient rounds (while member is admitted) and case conference (once member is discharged)

• Discharge planning

  • Partner with the TOC Care Coordinator and TOC Behavioral Health Specialist (as needed) to develop post-discharge care plans that address identified needs and barriers to support a smooth recovery

• Collaborate with TOC team for hand-off to longitudinal care at conclusion of the TOC program

• Collaborate with TOC team to determine need for escalation of member care

Clinical Visits and Follow-Up

• Regular check-ins with member as guided by TOC program

• Complete post-discharge home visit

• Weekly follow-up for four (4) weeks

• Ensure provider visit takes place (can be facilitated during home visit)

• Address and responds to member needs and delegate tasks in timely fashion

• Meet with members in the community (home, SNF, IRF, shelter, hospital) as needed, including as an extender of the care team for non-clinical needs

• Conduct comprehensive medication reconciliation

• Address contracted and company prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure

Operations

• Utilize our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources

• Manage the tracking of all metrics related to transitions of care for assigned members including logging new TOC events and accompanying follow up metrics.

Requirements for the Role:

• Graduate of an accredited school of nursing (R.N.)
• Basic Life Support (BLS) certification is a requirement
• Active RN License in the state(s) practicing
• Unrestricted Driver’s License
• 3+ Years of experience
• Interpersonal skills, clear and concise verbal and written communication.
• Ability to communicate clinical concepts to non-clinical staff
• Communicate effectively telephonically, virtually and in-person
• Actively listen to members, care team and other stakeholders to understand and effectively address needs
• Effectively communicate member needs to all stakeholders
• Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management
• Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation
• Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner
• Versed in Motivational Interviewing and Trauma Informed Care principles
• Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members
• Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members’ care and health
• Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities
• Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities

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.

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.

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.

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