Assessment RN - MA (Worcester)

#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. 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:

The Assessment RN completes MDS and relevant screenings within assigned territory as scheduled to capture members’ clinical needs and meet regulatory requirements, and also works with members to create a comprehensive care plan that accurately reflects members’ needs and healthcare goals. Uses clinical judgment to escalate members with urgent clinical needs to appropriate departments as needed 

• Engagement
  • Explain CItyblock’s model of care to members
• Assess/Intake
  • Completes MDS and/or Comprehensive member assessment.
  • Complete self-efficacy and relevant condition-specific screeners with members
    • Complete additional tools or screeners as needed, including relevant behavioral health screeners (e.g., PHQ9, GAD-7, AUDIT, DAST-10)
  • Triage members with need for behavioral health programming
  • Conduct an in-person clinical exam, if appropriate
  • Collaborate with care team members to determine need for member placement in a different program (e.g., lower or higher intensity programs)
• Care Planning
  • Develop initial care plan with the member and clearly document any clinical concerns identified during the assessment that the member declined to include in their care plan
• Clinical Visits
  • Medication reconciliation, adherence concerns and education 
  • Address contracted and company prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure and risk stratification 
• Operations
  • Utilize our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources

Requirements for the Role:

• Graduate of an accredited school of nursing (R.N.)
• Certified in Basic Life Support for Healthcare Providers
• Active RN License in the state(s) practicing
• Unrestricted Driver’s License
• Comfortable using technology to support members without in-person contact (telephone and text etiquette