RN Clinical Care Manager

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At Cityblock Health, our mission is to radically improve the health of urban communities, block by block. We integrate services to address physical, behavioral and social needs together, delivered through mobile, field-based care teams to make healthcare more accessible, supportive and goal-driven for the people who need it most.

Every aspect of the Cityblock care model is carefully designed to focus on our members, engaging and empowering them to own and improve their health through trusted relationships. Through field-based, interdisciplinary care teams, we are flexible in how we deliver care, meeting members where they are and together developing and working longitudinally through a personalized and integrated Member Action Plan (MAP). The care team collaborates to support each member’s whole health and social needs. Enabled by custom-built technology, we build capacity, deliver care and dramatically change members’ opportunities and outcomes.

Partnering with community-based organizations and a well-respected commercial partner in North Carolina and backed by the top healthcare investors in the country, we are reorganizing the health system to focus on what matters to our members—and leading the move from transactional, fee-for-service medicine towards high-value, relationship-based partnerships.

The role:
In this role, you will provide direct service to Cityblock members as part of our innovative care model, designed to address the complex health and social challenges of high-risk, high-need populations living in urban neighborhoods. You will be a mobile care provider, extending out in the surrounding neighborhood and community. It is integral to our care model that we meet people where they are, both physically and emotionally. Given this, your work will frequently take you out into the community to provide care in settings that work best for our members.

As an RN Clinical Care Manager, you will work with a panel of members to improve their health holistically. You will support members when they get sick, leave the hospital, receive new diagnoses, are preparing for a procedure, are managing their chronic illnesses, are in pain or when they need additional education. You will provide a necessary bridge to specialty care, homecare services and other facility services. Additionally, you will provide clinical support to our large team of Community Health Partners, who will serve as members’ main point-of-contact and coordinator. You will work alongside and will be supported by, a care team associated with each member, whose work is focused around a Member Action Plan (MAP).

What you will do:
• Follow a panel of members to provide, nursing clinical support, including transitional care, health maintenance, medication reconciliation, medication administration, chronic disease management and co-occurring psychiatric disorders.
• Continuous outreach to support building and maintaining member panels for team.
• Provide ongoing support to your panel of members, prioritizing visits based on their acuity.
• Meet with members in their homes, neighborhoods, at the point of hospital discharge and within the healthcare system individually or accompanying a Community Health Partner.
• Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions.
• Assist members with medication reconciliation, medication administration.
• Educate members about their conditions, tailoring your delivery to meet them where they are.
• Complete head to toe physical assessments in the home.
• Work daily within our custom-built care facilitation platform, which will enable you to collect data, organize information, track tasks and communicate with staff, members and family. This platform is being built for a mobile workforce and you will use our technology in the field, provide feedback to the product development team and, over time, become part of a super-user group to assist in onboarding and supporting others.
• With our field based model, teams are always on the move. We use technology to stay connected., You will need a comfort with a daily use of tech across multiple different platforms.
• Foster lasting and trusting relationships to assist members in achieving goals, identifying new needs and coordinating care.
• If certified and trained, assist with wound care and drawing blood in the home.
• Utilize critical thinking skills and excellent communication skills to manage complex clinical issues utilizing assessment skills and protocols.
• Leverage strong time management skills to ensure that we make the most impactful judgement calls as we care for a full panel of members and juggle competing priorities throughout the day.
• Operate as part of a care team leveraging your clinical expertise to foster collaborative discussions with all levels of discipline around member care, during scheduled meetings including daily team meetings and weekly case conference and on a case-by-case basis.
• Go above and beyond to connect with members and partners 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.

What a good fit looks like:
• You have a current, unrestricted North Carolina license.
• You have 3+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions.
• Willing to work a full-time 40 hour work week, Monday-Friday with Saturday Rotation.
• Familiarity and willing to travel within Charlotte (home-based member visits) and its healthcare systems (hospitals and rehab centers).
• Experience as an active participant in continuous quality improvement projects within a provider setting.
• Experience working with interdisciplinary care teams.
• Possess exceptional triage, coordination and clinical assessment skills.
• Phenomenal communicator; you approach care interactions with warmth and thoughtfulness.
• Demonstrated 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 believe deeply in a localized, community-based care model and are compelled by the mission that drives Cityblock Health.
Nice to have
• Experience working collaboratively with an interdisciplinary care team and specifically working alongside community health workers or care coordination staff.
• Experience in homecare, hospice, acute care and/or care management.
• Multi-lingual (Spanish, French Creole).
• Bachelor’s degree preferred.
• Unrestricted North Carolina Driver’s License and Car.
• Care Management Certification (CCM).

What you should include in your application:
• A resume and/or LinkedIn profile.
• A 1-2 paragraph response indicating why this job is compelling to you.
• A 1 paragraph summary of a time when you thought you made a difference in someone’s health.

Cityblock values diversity as a core tenet of the work we do and 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.

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