RN Case Manager - PG County

Cityblock Health

1d•Onsite

About The Position

The RN Case Manager (RNCM) manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care. 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. Cityblock Health is a tech-driven provider for communities with complex needs, founded in 2017 and backed by Alphabet’s Sidewalk Labs. Its mission is to improve the health of underserved communities, specifically Medicaid and lower-income Medicare beneficiaries, by bringing care into the home and neighborhoods through community-based care teams and Virtual Care offerings. Cityblock collaborates with community-based organizations, local providers, and health plans, utilizing custom care delivery technology to provide personalized primary care, behavioral health, and social services. The company is growing rapidly and seeks individuals who believe in providing good care for all members in their community, emphasizing diversity and inclusion. The team employs a field-based, home-based care model, committed to meeting members where they are--in their homes, in their community, and in our Hubs--and connecting with them in a non-judgmental, respectful and empathic manner.

Requirements

Must reside in Maryland and hold an active RN license in Maryland, or a multistate (compact) RN license in good standing with the ability to practice in Maryland.
3+ Years of experience
Graduate of an accredited school of nursing (R.N.)
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

Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals.
Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs.
Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity.
Prepare for and actively participate in case conferences, leading discussions when necessary.
Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner.
Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly.
Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support.
Perform medication reconciliation, administration, compliance, and education as part of member care.
Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures.
Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources.
Support members in achieving their care plan goals through coordinated and comprehensive care efforts.