Job Description:

The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy.

Responsibilities:

• Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals.

• Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs.

• Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity.

• Prepare for and actively participate in case conferences, leading discussions when necessary.

• Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner.

• Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly.

• Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support.

• Perform medication reconciliation, administration, compliance, and education as part of member care.

• Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures.

• Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources.

• Support members in achieving their care plan goals through coordinated and comprehensive care efforts.

Requirements for the role:

• 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/or Geriatric individuals with co-occurring chronic medical and behavioral health conditions

• Familiarity and willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals and rehab centers)

• Experienced in documentation, care planning, care coordination and have excellent writing skills

• Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and care coordination team members

• Must have 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.

Education:

• Graduate of an accredited school of nursing (R.N.)

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: 

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.

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.