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MDS RN - Worcester

Cityblock Health • Worcester, Massachusetts, United States • 5m ago

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 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

Engagement
- Explain CItyblock’s model of care to members
Assess/Intake
- Completes MDS and/or Comprehensive member assessment.
- 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)
Care Planning
- Develop initial care plan with the member and clearly document any clinical concerns identified during the assessment that the member declined to include in their care plan
Clinical Visits
- Medication reconciliation, adherence concerns and education
- 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 and risk stratification
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

Requirements for the Role:

Graduate of an accredited school of nursing (R.N.)
Certified in Basic Life Support for Healthcare Providers
Active RN License in the state(s) practicing
Unrestricted Driver’s License
Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)
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
Willing and able to pivot to various tasks as needed in order to best support the needs of the department

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.

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