Cityblock Health

Resource Nurse - Suffolk County

$90,000 - $104,000 / year
Job Description: Geographic Coverage: Primarily within Suffolk County, with a focus on Boston neighborhoods (e.g., Dorchester, South Boston, Roslindale, Mattapan, Hyde Park), and coverage in nearby north-of-Boston areas such as Everett, Revere, and Winthrop. 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: 90,000 - 104,000 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.
Cityblock Health

Assessment RN - Suffolk County

$95,000 - $104,000 / year
Job Description: Geographic Coverage: Primarily within Suffolk County, with a focus on Boston neighborhoods (e.g., Dorchester, South Boston, Roslindale, Mattapan, Hyde Park), and coverage in nearby north-of-Boston areas such as Everett, Revere, and Winthrop. The Assessment RN completes MDS and relevant screenings within assigned territory as scheduled to capture members’ clinical needs and meet regulatory requirements, and also works with members to create a comprehensive care plan that accurately reflects members’ needs and healthcare goals. Uses clinical judgment to escalate members with urgent clinical needs to appropriate departments as needed. Responsibilities: Explain Cityblock’s model of care to members, ensuring they understand the services available to them. Complete the Minimum Data Set (MDS) and/or comprehensive member assessments during the intake process. Conduct self efficacy and relevant condition specific screeners, including behavioral health assessments like PHQ9, GAD7, AUDIT, and DAST10. Triage members requiring behavioral health programming and conduct in person clinical exams when appropriate. Collaborate with the care team to assess if a member requires placement in a different program, whether a lower or higher intensity option is necessary. Develop an initial care plan with the member, clearly documenting any clinical concerns identified during the assessment that the member has declined to include. Focus on medication reconciliation during clinical visits, addressing adherence concerns and educating the member. Address contracted and company prioritized quality gaps, ensuring proper chart documentation and inclusion of necessary codes (ICD or CPT) for gap closure and risk stratification. Use care facilitation, electronic health records, and scheduling platforms to: Collect data Document member interactions Organize information Track tasks Communicate effectively with the team, members, and community resources. Work Experience: Varies based on experience 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: $95,000 - $104,000 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.
Cityblock Health

Medical Assistant - Charlotte, NC

$20.19 - $25.96 / hour
Job Description: The Medical Assistant provides direct services to members and performs various office and clinical duties to keep our healthcare practice running efficiently. Charlotte Hub Location: 4444 The Plaza Unit 18, Charlotte, NC 28215 Responsibilities: Answers phone calls and greet patients as they enter the facility Assists the nurse and office manager in maintaining the medical inventory and placing orders for new materials as needed. Assists healthcare providers with clinical procedures, examinations, diagnostics testing, specialized clinical procedures as authorized Administers medications and vaccines under the direction of a licensed healthcare provider. Outreaches / engages members to schedule provider visits for annual visits, discharge follow up, chronic disease management, and addresses HEDIS gaps Coordinates patient care activities, including scheduling appointments, obtaining referrals, and managing patient follow-up. Maintains accurate and up-to-date patient records, including entering information into electronic health record (EHR) systems. Manages the inventory of medical supplies and medications, reordering as needed. Completes pre- and post- visit chart prep for provider visits; ensures all quality and patient outcome metrics are elevated for providers to address. Work Experience: 1+ years of experience working in a clinical operations setting 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: $20.19 - $25.96 Hourly 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.
Cityblock Health

Nurse Practitioner or Physician Assistant- Family Medicine

$97,000 - $128,000 / year
Job Description: The Pod Provider (APC) delivers comprehensive chronic disease management (e.g. hypertension, diabetes, chronic kidney disease), evaluation of acute concerns, behavioral health condition management (i.e. depression, anxiety, alcohol and substance use disorder), and preventative care and wellness support (including sexual and reproductive health). The role works collaboratively with an interdisciplinary team of clinical and non-clinical members to develop member care plans and to support members throughout their care journey. The Pod Provider also assists with the development and enhancement of clinical programs, initiatives, processes, and policies. Schedule: Monday-Friday Clinic (Hub) Address: 2606 W. 12 mile Road Suite 202 Southfield, MI 48076 Responsibilities: Conduct comprehensive clinical intake visits. Provide longitudinal direct primary care or wrap-around care with focus on chronic condition management and preventative care. timely follow-up for members post transition of care event, acute need or according to condition-specific needs. Proactively outreach to members who need follow up care. Complete comprehensive and compliant diagnosis capture related to HCC (Hierarchical Condition Categories) and ICD-10 (International Classification of Diseases-10) Coding. Address contractual 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. Prescribe 1st and 2nd line medications for depression, anxiety, alcohol use disorders and opioid use disorders. Remain up to date on evidence-based care for complex patients in primary care: (adult only, pediatric in certain markets). Refer member to specialist care appropriately and according to internal CBH guidance if available. Support the member in achieving the goals in their care plans (physical, behavioral, and/or social health). Participate in case conferences with the care team, providing clinical expertise on care plan development. Provide guidance on highest impact clinical interventions and tasks to achieve a member’s goals. Collaborate on a panel of members to provide clinical input, including health maintenance, chronic disease management and co-occurring psychiatric disorder support. Work Experience: 3+ experience 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: $97,000.00 - $128,000.00 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.
Cityblock Health

Lead, RN Care Manager - Essex/Middlesex County

$87,000 - $115,000 / hour
Job Description: The RNCM Lead is a highly skilled and experienced nurse leader, who is responsible for providing clinical, operational, administrative, and leadership to the RN team. The RN lead is accountable for onboarding, training, and ongoing performance and productivity management of RNCMs. The RN Lead also supports the Sr. RNCM and other RNCMs with member escalations or other clinical needs, as they arise. The RN Lead partners closely with other clinical and operational leaders in the market. Responsibilities: Provide comprehensive clinical, operational, administrative, and managerial support to the RN team, monitoring performance and productivity metrics while promoting professional learning, training, and clinical development. Collaborate with market nursing leadership, Community Health Partner (CHP) leadership, and medical leadership to ensure clinical and operational excellence across the organization. Plan and execute coverage strategies to enhance market performance, effectively managing and resourcing a skilled workforce dedicated to delivering member focused, efficient, and quality driven care services. Develop, implement, and administer operational processes and policies to improve member and client satisfaction, as well as overall efficiency, quality, and productivity. Leverage technology and drive continuous improvement and transformational change initiatives to optimize business processes within the assigned area of coverage. Communicate and collaborate with management, supervisors, and staff to identify operational challenges and opportunities, fostering innovative solutions that promote operational excellence. Create a high engagement workforce environment by coaching staff, setting expectations, conducting performance appraisals, and offering career development opportunities, succession planning, and recognition for achievements. Partner with the Senior Nurse Manager to develop and maintain daily, weekly, monthly, and quarterly reports along with key performance indicators to track progress and ensure accountability. Work Experience: 2+ years of Nursing Management Experience. 3+ years of Care Management Experience Education: Bachelor's degree 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: $87,000.00 - $115,000.00 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.
Cityblock Health

RN Care Manager- North Carolina

$71,000 - $90,500 / year
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.
Cityblock Health

RN Case Manager, Transition of Care (TOC) - PG County

$71,000 - $90,500 / year
Job Description: PG County 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. Responsibilities: Assign members and initiate outreach by contacting hospital case managers to understand each member's unique needs before engaging them in the TOC program. Complete self-efficacy and condition-specific screeners during the assess and intake phase, including behavioral health tools like PHQ-9, GAD-7, AUDIT, or DAST-10, to identify members requiring behavioral health programming. Conduct in-person clinical exams if appropriate and collaborate with care team members to determine if a different intensity program placement is needed. Participate in daily inpatient rounds while members are admitted, followed by post-discharge case conferences to support discharge planning. Collaborate with the TOC Care Coordinator and TOC Behavioral Health Specialist to develop post-discharge care plans addressing needs and barriers, ensuring smooth recovery and effective hand-off to longitudinal care. Perform regular check-ins guided by the TOC program, including post-discharge home visits and weekly follow-ups for four weeks, ensuring provider visits are completed and addressing member needs promptly. Meet members in various community settings such as homes, SNFs, IRFs, shelters, and hospitals, providing support for both clinical and non-clinical needs. Conduct comprehensive medication reconciliation and address contracted and company-prioritized quality gaps, ensuring proper chart documentation and appropriate ICD or CPT coding as evidence of gap closure. Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources. Track TOC-related metrics for assigned members, logging new TOC events and follow-up metrics to monitor progress effectively. 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.