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Registered Nurse - Transitions of Care

Company: Cityblock Health, Inc
Location: Cincinnati
Posted on: August 7, 2022

Job Description:

Family Practice/Primary Care opening in Cincinnati, Ohio. This and other rn jobs brought to you by

#communityhealth #healthcare

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, 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.
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 members in our 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:
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 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

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


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.
Work a full-time 40 hour week, with the potential of covering the after hours on-call rotation,
Participate in team meetings, role-specific meetings, case conference, supervision, and field-based independent clinical and co-visits.
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
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

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.

Cityblock is not hiring for this position in the state of Colorado.

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.

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.

Keywords: Cityblock Health, Inc, Cincinnati , Registered Nurse - Transitions of Care, Healthcare , Cincinnati, Ohio

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