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Perinatal Care Team Lead/RN Care Manager

Cityblock Health
Charlotte, North Carolina
Closing date
Jan 18, 2022

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Registered Nurse (RN)
Position Type
Full Time
Work Setting
Hospital / Medical Center
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#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:

In this role, you will provide direct service to Cityblock members as part of our innovative pregnancy care model, designed to address the complex health and social challenges of our birthing members. It is integral to our care model that we meet people where they are, both physically and emotionally. Given this, your work will take you out into the community to provide care in settings that work best for our members.

Reporting to the Pregnancy Program Clinical Lead and with a dotted line to the North Carolina Operations Director, you will lead the day to day functions of a care team made up of Perinatal Community Health Partners (PCHPs) while functioning as a Nurse Care Manager focused on the needs of our high-risk pregnant and postpartum population. You will support team members in meeting their metrics and goals. You will work collaboratively with a Behavioral Health Specialist and a Nurse Midwifewho will provide additional clinical oversight for members served by this Pregnancy Care Team. You will provide coaching, support and supervision to our PCHPs, a team that serves as the heartbeat of our care model. In managing and leading a team of PCHPs, you will support and develop them as they outreach, engage and guide members through their Member Action Plans (MAPs).

You will:
  • Provide supervision and leadership for a team of Perinatal Community Health Partners (PCHPs), supporting them in meeting population level expectations.
  • Provide guidance, coaching, and training around engagement, care planning, and longitudinal care.
  • Support PCHPs through their member outreach and engagement efforts.
  • Hold CHPs accountable for completing a comprehensive assessment of members' health needs, including physical, behavioral and social, while supporting appropriate boundaries in PCHP scope of care.
  • From that assessment, support the development of member-driven, member-centered action plans that address social needs.
  • Model how to foster lasting and trusting relationships by doing so with your team and your members.
  • Act as a point person for the members on your team's panels; co-visit members with PCHPs, provide assistance in crises, etc.
  • Aim to spend approximately 12 hours of your time on Direct Member Care (visits). This should be adjusted based on member need.
  • Support your team to work with members longitudinally to achieve their goals and identify new needs.
  • Conduct home visits, including scheduled and unscheduled episodic urgent member needs
  • Provide ongoing clinical support to your panel of members in partnership with your interdisciplinary care team, prioritizing member visits based on their health needs
  • Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
  • Assist members with medication reconciliation, medication administration & medication compliance
  • Leverage strong time management skills to to make impactful judgement calls on member care and balance with daily team meetings, weekly case conferences, and skill-building workshops
  • Utilize our custom-built care facilitation platform, Commons, and the market's EMR to collect data, document member interactions in the field, organize information, track tasks, and communicate with your team, members, and community resources

Requirements for the Role:
  • Active, unrestricted Registered Nurse license in the state in which you are seeking employment with Cityblock
  • Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with one late evening a week, consisting of team meetings, case conference, supervision, and field-based independent clinical and co-visits.
  • You have experience providing supervision to community health workers, or care coordinators
  • You have experience leading the day-to-day operations of interdisciplinary teams
  • You have direct experience supporting at-risk populations with complex needs
  • You are an independent self-starter, a leader, and a strategic thinker who is excited about the big picture of whole community health, and the ongoing evaluation and iteration of our care model.
  • Familiarity and willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals)
  • Experience in transitions of care management, both in-person and virtual
  • Experience as an active participant in continuous quality improvement projects within a provider setting
  • Possess exceptional triage, coordination and clinical assessment skills
  • Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy), assessment and care plan reinforcement for common problems of pregnancy and the postpartum period, including chronic conditions such as diabetes, hypertension, depression.
  • Demonstrate the ability to affect change, and have been effective in helping a member or patient adapt new habits, or change behaviors
  • You are excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care.
  • You can accommodate a full time schedule as well as participate in on-call and Saturday coverage rotation.
  • Training in Motivational Interviewing and Conflict Resolution
  • Familiarity with community resources and social benefits
  • You have an unrestricted driver's license and a vehicle available for use

How We Define Success:
  • Manage a Care Team that meets the identified metric targets of a given market
  • Proactive problem solver who raises potential issues with a proposal.
  • Fiercely prioritize highly collaborative member care with examples to back it up.
  • People manager with a track record of coaching, and performance managing the care team.
  • Demonstrated dedication to leading through inclusion within your team
  • Engage in target setting for new clinical initiatives and managing those targets
  • Co-manage a panel of pregnant/postpartum members to address their long and short-term health needs, ultimately to prevent avoidable hospital and ED visits

Nice to Have, But Not Required:
  • Experience coordinating multi-disciplinary care for members with multiple complex medical and social conditions
  • Training in problem-solving therapy
  • Multi-lingual and bicultural

What We'd Like From You:
  • A resume and/or LinkedIn profile
  • A short cover letter, please!

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. Ciytblock will not pay fees associated with resumes presented through unsolicited means.

    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.
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