Assessment RN - North Worcester County - Hybrid

Cityblock Health•Worcester, MA

6d•Hybrid

About The Position

The Assessment RN completes MDS and relevant screenings within assigned territory as scheduled to capture members’ clinical needs and meet regulatory requirements. This role also works with members to create a comprehensive care plan that accurately reflects members’ needs and healthcare goals. The Assessment RN uses clinical judgment to escalate members with urgent clinical needs to appropriate departments as needed. This is a Field-Based Hybrid role, with up to approximately 80% in-person/community-based work, generally averaging approximately three member assessment visits per day based on member and business needs, with remaining work completed virtually/remotely subject to change. Mileage for approved business travel is reimbursed in accordance with company policy.

Requirements

Graduate of an accredited school of nursing (R.N.)
3+ Years of experience
Strong critical thinker with sound clinical judgment who makes complex decisions independently and knows when to collaborate.
Identifies system barriers to care and develops creative, practical solutions.
Demonstrates a growth mindset and openness to innovative approaches to improve outcomes.
Strong written and verbal communicator across phone, text, virtual, and in-person settings.
Comfortable using technology to engage members remotely.
Applies Motivational Interviewing and Trauma-Informed Care principles to build trust.
Effectively translates clinical information for non-clinical audiences and actively listens to understand and address needs.
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.

Responsibilities

Explain Cityblock’s model of care to members, ensuring they understand the services available to them.
Complete the Minimum Data Set (MDS) and/or comprehensive member assessments during the intake process.
Conduct self efficacy and relevant condition specific screeners, including behavioral health assessments like PHQ9, GAD7, AUDIT, and DAST10.
Triage members requiring behavioral health programming and conduct in person clinical exams when appropriate.
Collaborate with the care team to assess if a member requires placement in a different program, whether a lower or higher intensity option is necessary.
Develop an initial care plan with the member, clearly documenting any clinical concerns identified during the assessment that the member has declined to include.
Focus on medication reconciliation during clinical visits, addressing adherence concerns and educating the member.
Address contracted and company prioritized quality gaps, ensuring proper chart documentation and inclusion of necessary codes (ICD or CPT) for gap closure and risk stratification.
Use care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources.