Assessment RN - Suffolk County

Cityblock Health

3d•Hybrid

About The Position

Cityblock Health is the first tech-driven provider for communities with complex needs, aiming to bring better care to where it's needed most. Founded in 2017, Cityblock is backed by Alphabet's Sidewalk Labs and top healthcare investors. Their mission is to improve the health of underserved communities, focusing on Medicaid and lower-income Medicare beneficiaries. They deliver personalized primary care, behavioral health, and social services through community-based care teams and Virtual Care offerings, collaborating with community organizations, local providers, and health plans. The Assessment RN plays a crucial role in this model by completing assessments, developing care plans, and ensuring members understand available services.

Requirements

Varies based on experience
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.

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.