Transitions of Care (TOC) RN Care Manager - OH (RN )
Company: Cityblock Health, Inc
Location: Worcester
Posted on: August 5, 2022
Job Description:
Clinical Manager/Admin opening in Worcester, Massachusetts.
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:
As a Readmissions Nurse, you will coordinate with the member, their
case manager and the internal Cityblock care teams to ensure a safe
transition from the health care setting to their home, and that
they do not return to the hospital. This includes meeting with the
member at the healthcare setting, reconciling medications, meeting
the member in their home and ensuring the member has what they need
to be able to stay safe and at home.
More specifically, you will be part of a new Readmission Reduction
Team that will be accountable for managing the post-discharge and
readmissions processed. This team will manage members
post-discharge for a 30-day period and respond in real-time to
readmissions that occur.
- 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 in
partnership with the Readmissions Community Health Partner.
- You will maintain a fluctuating panel shared with the
Readmissions Community Health Partner of anywhere between 30-120
members as they cycle through the 30-day post-discharge period,
depending on the volume of admissions and readmissions
- Conduct 5-7 home visits in a given day to ensure post D/C
follow up (med rec, care coordination, provider visit
connection)
- Own the end-to-end readmission prevention process
post-admission; this includes, but is not limited to:
- Identify : Monitor our internal HIE alert system to quickly
outreach to members admitted or readmitted to the hospital or
facility
- Assess :
- Telephonic and in-person outreach to the member and their case
managers post hospitalization, ER visit or Skilled Nursing stay to
conduct a comprehensive assessment that includes medical,
behavioral, pharmaceutical and social needs to improve health and
reduce risk of readmission
-
- Engage:
-
-
- 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
-
- Timely Contact Post Discharge:
-
-
- Assess the member s knowledge of their clinical condition and
provide education and self-management guidance based on the member
s unique learning style
- Conduct in-home visit to assess safety and risks and implement
evidence-based interventions and protocols for complex chronic
conditions
- Assist members with medication reconciliation, medication
administration & medication management
-
- Proactive Mitigation:
-
-
- Weekly follow up by the Readmissions Reduction Team with the
member consistently for 30 days post-discharge to prevent
readmission
-
-
- Ensure that the member successfully has a visit with either
their PCP or a Cityblock provider post-discharge
-
-
- Coordinate care by serving as the member s advocate with our
internal care teams, the attending physician and case manager and
the member s family
-
- Return to ED Outreach:
-
-
- Respond to return to ED HIE ping within a timely manner in
attempts to avoid admission
-
- Warm Handoff of Members to Long-Term Cityblock Care Team:
-
-
- Within the 30 day post d/c period fully enroll member to
Cityblock Health
- Comfortable reaching out to new unknown people and following
leads to make contact with members
- Leverage strong time management skills to to make impactful
judgement calls on member care and balance with daily team meetings
and skill-building workshops
- 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
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 as a Transition of Care Nurse
or Post discharge work.
- Your day to day will be a combination of in home visits,
virtual visits and telephonic visits.
- Each RN is required to be 1st on call to support and triage
member calls after hours and weekends which is scheduled in
collaboration with your manager/supervisor.
- You own a car in order to visit members where they are
- Experience and comfort working within an interdisciplinary care
team, and specifically working alongside community health workers
and care coordination team members
- Experience managing a panel of members
- 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
- 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
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.
Locations:
Cityblock is not hiring for this position in the state of
Colorado.
..... click apply for full job details
Keywords: Cityblock Health, Inc, Worcester , Transitions of Care (TOC) RN Care Manager - OH (RN ), Executive , Worcester, Massachusetts
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