#communityhealth #healthcare

About Us:

Cityblock Health is the first tech-driven provider for communities with complex needs—bringing better care to where it’s needed most, block by block. Founded in 2017 on the premise that “health is local” and based in Brooklyn, we are backed by Alphabet’s Sidewalk Labs along with some of the top healthcare investors in the country.

Our mission is to improve the health of underserved communities. Importantly, our solutions are designed specifically for Medicaid and lower-income Medicare beneficiaries, and we meet our members where they are, bringing care into the home and neighborhoods through our community-based care teams and Virtual Care offerings.

In close collaboration with community-based organizations, local providers, and leading health plans, we are reorganizing the health system to focus on what matters to our members. Equipped with world-class, custom care delivery technology, we deliver personalized primary care, behavioral health, and social services to deliver a radically better experience of care for every member and community we serve.

Over the next year, we’ll grow quickly to bring better care to many more members and their communities. To do this, we need people who, like us, believe that everyone should have good care for what matters to them, in their community. 

Our work is grounded in a belief in the power of a diverse community. To close gaps in care and advance equity in the communities we serve, we have to start with making our own team diverse and inclusive. Our ways of working are characterized by creativity, collaboration, and mutual learning that comes from bringing together a community from diverse backgrounds and perspectives. We strive to ensure that every person on the Cityblock team, and every Cityblock member, feels supported and included as a part of our community.

Our Values:

  • Aim for Understanding
  • Be All In
  • Bring Your Whole Self
  • Lean Into Discomfort
  • Put Members First

About our Team: 

We employ a field-based, home-based care model and are committed to meeting members where they are--in their homes, in their community, and in our Hubs. You will go above and beyond to connect with Cityblock members in a non-judgmental, respectful and empathic manner, to meet their needs, and to provide feedback to the system as a whole as we strive to do better every day.

About the Role:

Cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community. The TOC Registered Nurse Care Manager (RNCM) coordinates with hospital case managers to determine members’ needs and to complete discharge visits (in-home or virtual) with members and providers. The TOC RNCM will also be available for referrals to triage members’ needs and provide clinical education, with the goal of helping ensure that members do not return to the hospital.

Engagement

  • Receive assignment of members 
  • Reach out to hospital case manager to understand member needs
  • Reach out to member to engage for TOC program

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

  • Participate in daily inpatient rounds (while member is admitted) and case conference (once member is discharged)
  • Discharge planning 
    • Partner with the TOC Care Coordinator and TOC Behavioral Health Specialist (as needed) to develop post-discharge care plans that address identified needs and barriers to support a smooth recovery
  • Collaborate with TOC team for hand-off to longitudinal care at conclusion of the TOC program
  • Collaborate with TOC team to determine need for escalation of member care

Clinical Visits and Follow-Up

  • Regular check-ins with member as guided by TOC program
  • Complete post-discharge home visit 
  • Weekly follow-up for four (4) weeks
  • Ensure provider visit takes place (can be facilitated during home visit)
  • Address and responds to member needs and delegate tasks in timely fashion
  • Meet with members in the community (home, SNF, IRF, shelter, hospital) as needed, including as an extender of the care team for non-clinical needs
  • Conduct comprehensive medication reconciliation
  • 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

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
  • Manage the tracking of all metrics related to transitions of care for assigned members including logging new TOC events and accompanying follow up metrics.

Requirements for the Role:

  • Graduate of an accredited school of nursing (R.N.)
  • 3+ Years of experience
  • Basic Life Support (BLS) certification is a requirement
  • Active RN License in the state(s) practicing Unrestricted Driver’s License
  • Contain interpersonal skills, clear and concise verbal and written communication.
  • Ability to communicate clinical concepts to non-clinical staff
  • Communicate effectively telephonically, virtually and in-person
  • Actively listen to members, care team and other stakeholders to understand and effectively address needs
  • Effectively communicate member needs to all stakeholders
  • 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
  • Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner
  • Versed in Motivational Interviewing and Trauma Informed Care principles
  • Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members
  • Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members’ care and health
  • Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities
  • Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities

What We’d Like From You:

  • A resume and/or LinkedIn profile

 

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.

-

We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means. 

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.

 

Covid 19 Update - Please Read:

Cityblock requires those hired into this position to provide proof that they have received the COVID-19 vaccine.  Any individuals subject to this requirement may submit for consideration a request to be exempted from the requirement (based on a valid religious or medical reason) on forms to be provided by Cityblock.  Such requests will be subject to review and approval by the Company, and exemptions will be granted only if the Company can provide a reasonable accommodation in relation to the requested exemption.  Note that approvals for reasonable accommodations are reviewed and approved on a case-by-case basis and availability of a reasonable accommodation is not guaranteed. This vaccination requirement is based, in part, on recently established government requirements.  The requirement is also based on the safety and effectiveness of the vaccine in protecting against COVID-19, and our shared responsibility for the health and safety of members, colleagues, and community.

 
The COVID-19 pandemic has severely impacted the health and lives of people around the world, including the vulnerable populations Cityblock serves. As a healthcare provider, Cityblock holds ourselves to the highest standards when promoting the health and safety of those who we serve. Given that the COVID-19 vaccines are one of the most powerful tools to fight this disease and save lives, Cityblock is implementing a COVID-19 booster mandate for Washington, D.C. employees under the guidance of local/state mandates.

Apply for this Job

* Required

resume chosen  
(File types: pdf, doc, docx, txt, rtf)
cover_letter chosen  
(File types: pdf, doc, docx, txt, rtf)
When autocomplete results are available use up and down arrows to review
+ Add another education


Voluntary Confidential Diversity & Inclusion Survey

Completing this survey is entirely voluntary.

We take equal opportunity seriously here at Cityblock and are working to build a company that is as diverse as the communities we serve. Completing this survey is voluntary, but we hope that you will choose to answer. All responses are kept completely private - they cannot be seen by anyone reviewing your application, they are  not used for or against your candidacy in any way.

Because the EEOC identifying questions are limiting, we would like to provide more options to our candidates to self identify for their gender, race, and age.

Our work here at Cityblock is grounded in a belief in the power of a diverse community. To close gaps in care and advance equity in the communities we serve, we have to start with building a diverse and inclusive team. Our ways of working are characterized by creativity, collaboration, and mutual learning that comes from bringing together a community from diverse backgrounds and perspectives. We strive to ensure that every person on the Cityblock team, and every Cityblock member, feels supported and included as a part of our community. 

Individuals seeking employment here at Cityblock are considered without regard to race, color, religion, national origin, age, sex, marital status, ancestry, physical or mental disability, veteran status, gender identity, or sexual orientation.

Thank you!

What are your pronouns?





What sex were you assigned at birth? (Select one)




With what gender do you currently identify?






Do you identify as a part of the LGBTQIA+ community? (Select one)



What is your race and/or ethnicity? Select all that apply.











Voluntary Self-Identification

For government reporting purposes, we ask candidates to respond to the below self-identification survey. Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file.

As set forth in Cityblock Health’s Equal Employment Opportunity policy, we do not discriminate on the basis of any protected group status under any applicable law.

Race & Ethnicity Definitions

If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection. As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categories is as follows:

A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.


Voluntary Self-Identification of Disability

Form CC-305
Page 1 of 1
OMB Control Number 1250-0005
Expires 04/30/2026

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

  • Alcohol or other substance use disorder (not currently using drugs illegally)
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
  • Blind or low vision
  • Cancer (past or present)
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or serious difficulty hearing
  • Diabetes
  • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
  • Epilepsy or other seizure disorder
  • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
  • Intellectual or developmental disability
  • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
  • Missing limbs or partially missing limbs
  • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
  • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
  • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
  • Partial or complete paralysis (any cause)
  • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
  • Short stature (dwarfism)
  • Traumatic brain injury

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.


Our system has flagged this application as potentially being associated with bot traffic. Please turn off any VPNs, clear your browser cache and cookies, or try submitting your application in a different browser. If this issue persists, please reach out to our support team via our help center.
Please complete the reCAPTCHA above.