Hub RN - NC (Fayetteville)

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:

The Hub RN provides nursing support for the care team, and is available to support and consult on member-specific needs (e.g., in-person visits, clinical education, targeted clinical interventions). The HUB RN also ensures safe and compliant clinic operations from a nursing perspective with occasional crossover into the provision of community health minded services.

• Engagement
  • Receive incoming calls from members that require clinical triage
  • Provide decision support about when visits require urgent clinical response
• Assess/Intake
  • Ensure clinical safety and appropriate triage of on-site members
  • Perform additional assessments or pre-visit testing that are non-standard, as requested by provider
  • Conduct an in-person clinical exam, if appropriate
• Case Review
  • Participate in interdisciplinary case conference as needed
  • Run campaigns for population health focus (e.g., vaccination campaigns, lost-to-care lists)
  • Serve as clinical resource for team members, assisting with clinical goals, education and acute clinical needs
• Clinical Visits, Practices & Procedures
  • Triage needs and provide clinical education
  • Call members with test results 
  • Address and respond to member needs and delegate tasks in timely fashion
  • Provide episodic care management for identified members
  • Meet with members in the hub as extenders of the primary care providers and other care team members, including medication reconciliation, standing orders, minor procedures, DME coordination, imaging management, prior authorization, and disease management education and oversight
  • Cross-over support of Medical Assistant duties (e.g., rooming, vitals, drawing labs, EKGs, and injections)
  • Safe escalation or hand-off to longitudinal care providers
  • Provide care team support from a nursing perspective, and act as a bridge between on-site care and field-based care
  • Medication reconciliation, administration, compliance, and education; medication refills per standing protocol or provider order
  • 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
• Clinic Operations
  • Ensures safe and compliant clinic operations from a nursing perspective with occasional crossover into provision of community health minded services. Familiarity with basic maintenance of the outpatient environment of care.
  • Utilize our care facilitation and electronic health record platforms to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources
  • Ensure appropriate FIT testing and PPE for all levels of Covid/respiratory exposure
  • Place orders for vaccines and maintain temperature control including data logger monitoring 
  • Manage clinical stock inventory supplies for community care and coordinate distribution of nursing bag kits
• Clinical Education and Training
  • Provide teaching related to medical equipment and provide continuing education for chronic disease management to those with less intensive training (e.g., Medical Assistants, Community Health Partners)
  • Review clinical competencies with Medical Assistants; train and provide sign-off of clinical competencies with Medical Assistants (including Point-of-Care Testing or procedures)
• Operations and Reporting
  • 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

Requirements for the Role:

• Graduate of an accredited school of nursing (RN)
• 3+ Years of experience
• Active RN License in the state(s) practicing
• Unrestricted Driver’s License
• Basic Life Support (BLS) certification is a requirement
• 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
• Skilled in safe vaccine administration across adults and pediatric populations, including proper site selection, cleansing techniques, administration, and providing education and post vaccine monitoring needs
• 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.

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