Job Description

About the Role

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.

Hybrid Role: Mix of virtual and In-Facility or Home

Monday- Friday: 8:30am-5pm

Must live in the Bronx area

Responsibilities:

Engagement

• Receives members from engagement and care team
• Describe program expectations (e.g., length) and goals to members

Assess/Intake

• 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)

Case Review and Care Planning

• Prep and active participant in case conference, leading discussion as appropriate
• Develop care plan with the member, collaborate with Community Health Partner on social needs as needed

Clinical Visits and Follow-Up

• Regular check-ins with member as guided by program
• Follow-up on routine therapeutic interventions by internal or external providers (in collaboration with care team)
• Address and responds to member needs and delegate tasks in timely fashion
• Collaborate on a panel of members assigned to your care team to provide clinical support, including health maintenance, chronic disease management and co-occurring psychiatric disorder support
• Medication reconciliation, administration, compliance, education and home monitoring
• 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
• Support members in achieving their care plan goals

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:

• 3+ Years of RN experience
• Bilingual Spanish
• Graduate of an accredited school of nursing (R.N.)
• Unrestricted RN license in the state of New York
• Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)
• Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management
• Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation

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:

$115,000- $119,000 Annually

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.