Job Description: Location: This role supports members across Gardner, Athol, Fitchburg, Leominster, Clinton, Worcester, and nearby communities Work Model: Hybrid, with an estimated 70% of time spent in the field and 30% working remotely The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. 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. 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. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. 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. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
Job Description: Worcester /Middlesex Territory includes but not limited to: Gardner, Athol, Fitchburg, Leominster, Clinton, Worcester Hybrid Apx: 1–2 in-person visits/day (~5–6/week), rest virtual Hybrid ~70% in-field / 30% remote The Resource RN provides nursing support to the care team, serving as a bridge between the care management team, hub-based clinical team and members. The Resource RN is available to support and consult on member-specific needs (e.g., in-person visits, clinical education, targeted clinical interventions), and is home based, meaning days will primarily be virtual, but can go into the field on occasion. The Resource RN does not carry a panel, however the RN may work lists of members for targeted clinical reasons. Responsibilities: Support the Member Navigator during the assessment and intake phase to ensure assessments are accurately interpreted and appropriately triaged. Collaborate with care team members for case review and care planning, signing off on care plans, determining escalations, and resolving barriers to effective care. Act as a clinical resource, assisting team members with clinical goals, education, and addressing acute clinical needs. Conduct medication reconciliation, administration, compliance, and education during clinical visits and procedures, including processing medication refills per established protocols or provider orders. Meet members in various community settings such as homes, SNFs, shelters, or hospitals, serving as an extender of care team providers and performing tasks like administering injections, monitoring vital signs, conducting global assessments, facilitating minor procedures, and in-home medication reconciliation. Utilize preventive health screening tools and coordinate DME fit and education while providing in-home disease management education and wound assessments and care. Perform blood draws and reinforce care plans for chronic conditions such as diabetes, hypertension, heart failure, and depression. Address quality gaps prioritized by contracts and the organization, ensuring proper chart documentation and coding (ICD or CPT) as evidence of gap closure. Ensure members receive necessary LTSS with clinical justifications provided to meet service criteria, maintaining communication with relevant stakeholders. Provide nursing perspective support to the care team, bridging on-site and field-based care to ensure seamless transitions. Facilitate follow-ups by handing off members to the longitudinal care team for continued engagement and prioritizing timely responses to member needs with appropriate task delegation. Triage referral needs and provide clinical education to support members in achieving their care plan goals. Schedule shadowing and field training for new RN care managers and deliver training on medical equipment and chronic disease management to less intensively trained staff such as Medical Assistants and Community Health Partners. Support operational efficiency by utilizing care facilitation, electronic health records, and scheduling platforms for data collection, member interaction documentation, information organization, task tracking, and effective communication with team members and community resources. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. 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. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
Job Description: Worcester/Norfolk The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. 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. 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. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. 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. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
Job Description: The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. 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. 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. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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.
Job Description: Baltimore, MD The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. 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. 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. Work Experience: 3+ Years of experience Education: Graduate of an accredited school of nursing (R.N.) We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: $71,000.00 - $90,500.00 Annual 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. 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. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
