RN Care Manager- North Carolina- Hybrid

Cityblock Health•Greensboro, NC

4d•$90,000 - $95,000•Hybrid

About The Position

The RN Care Manager manages a panel of rising- and high-intensity members, supporting integrated chronic disease and behavioral health care. The role collaborates with members to develop care plans and oversee progress, regularly reassesses needs, coordinates with providers and specialized resources, and partners closely with Community Health Partners to build trust and advocate for members. The RN Care Manager conducts assessments and clinical follow-ups, supports care planning and coordination, and works with an interdisciplinary care team to address health maintenance, chronic conditions, behavioral health, and social needs. The role also supports medication management, quality-gap closure, and accurate documentation using care facilitation tools and electronic health records. This is a hybrid position serving North Carolina, with travel for home-based member visits and visits to healthcare systems such as hospitals and rehabilitation centers.

Requirements

Active, unrestricted Registered Nurse license in the state where employment with Cityblock is sought.
At least 3 years of experience providing clinical services to adults and/or geriatric individuals with co-occurring chronic medical and behavioral health conditions.
Familiarity with and willingness to travel within the community for home-based member visits and to healthcare systems, including hospitals and rehabilitation centers.
Experience with documentation, care planning, and care coordination, along with excellent writing skills.
Experience and comfort working within an interdisciplinary care team, including alongside community health workers and care coordination team members.
Prior experience with, or willingness to train in, clinical nursing skills such as wound assessment and care, blood drawing (venipuncture and phlebotomy), and assessment and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, and depression.
Graduate of an accredited school of nursing (R.N.).

Responsibilities

Receive members from the engagement and care team and communicate program expectations, including duration and goals.
Complete self-efficacy, condition-specific, and behavioral health screeners during assessment and intake, including PHQ-9, GAD-7, AUDIT, and DAST-10.
Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine program placement and intensity.
Prepare for and participate actively in case conferences, leading discussions when necessary.
Develop care plans with members and address social needs with support from the Community Health Partner.
Conduct regular clinical visits and follow-ups according to program guidelines, monitor routine therapeutic interventions, and respond promptly to member needs.
Collaborate with the care team to support assigned members through health maintenance, chronic disease management, and support for co-occurring psychiatric disorders.
Perform medication reconciliation, administration, compliance support, and education as part of member care.
Address quality gaps prioritized by the contracted company and document and code care thoroughly using ICD or CPT to validate gap closures.
Use care facilitation tools, electronic health records, and scheduling platforms to gather data, document interactions, organize information, track tasks, and communicate with team members and community resources.
Support members in achieving care plan goals through coordinated and comprehensive care.