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 members in the Washington DC communities 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:
You will work in a radically different model of healthcare
Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners
Co-manage a population living with complex medical and behavioral health conditions
Collaborate on a panel of members assigned to your care team to provide, nursing clinical support, including transitional care, health maintenance, medication reconciliation & administration, chronic disease management and co-occurring psychiatric disorders
Your work will take you into the community. You will meet with members in their homes, 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 care team members (i.e. Community Health Partners, Behavioral Health Specialists, Nurse Practitioners)
Conduct several home visits in a given day, including scheduled and unscheduled episodic urgent member needs
Provide ongoing clinical support to your panel of members in partnership with your interdisciplinary care team, prioritizing member visits based on their health needs
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
Leverage strong time management skills to to make impactful judgement calls on member care and balance with daily team meetings, weekly case conferences, and skill-building workshops
Foster lasting and trusting relationships to assist members in achieving goals, identifying new needs, and coordinating care
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
Put Members First
Bring Your Whole Self
Be All In
Aim For Understanding
Lean Into Discomfort
Active, unrestricted Registered Nurse license in the state in which you are seeking employment with Cityblock
You have 3+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions
Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with one late evening a week, consisting of team meetings, case conference, supervision, and field-based independent clinical and co-visits.
Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and care coordination team members
Familiarity and willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals and rehab centers)
Experience in transitions of care management, both in-person and virtual
Experience as an active participant in continuous quality improvement projects within a provider setting
Possess exceptional triage, coordination and clinical assessment skills
Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy), assessment and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, depression.
Demonstrate the ability to affect change, and have been effective in helping a member or patient adapt new habits, or change behaviors
Excited about how technology can support your work and help drive the ongoing evaluation toward new and better care
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
You will also participate in a regular Saturday Rotation and the Cityblock on-call schedule. Your work may take you outside of normal business hours as urgent member needs arise
Internal Number: 2020-155
About Cityblock Health
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, one block at a time. 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.
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. We will get started in new ...markets, each with their own operating structure and care teams, and continue to grow in the communities where we are working already. 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.