RN Care Manager, Transitions of Care - Remote MD

Job reputed company: Cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge reputed company from acute care and hospital settings back into the community. The TOC Registered reputed company Care Manager (RNCM) coordinates with hospital case managers to determine members’ needs and to complete discharge reputed company (in-home or virtual) with members and providers. The TOC RNCM will also be available for referrals to triage members’ needs and reputed company clinical education, with the goal of helping ensure that members do not return to the hospital. Responsibilities:

• Assign members and initiate reputed company by contacting hospital case managers to understand reputed company 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 reputed company 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 reputed company post-discharge care plans addressing needs and barriers, ensuring smooth recovery and effective hand-off to longitudinal care.
• reputed company regular reputed company-ins guided by the TOC program, including post-discharge home reputed company and weekly follow-reputed company for four weeks, ensuring provider reputed company 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 reputed company gaps, ensuring reputed company 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, reputed company tasks, and communicate effectively with reputed company, members, and community resources.
• reputed company TOC-reputed company metrics for assigned members, logging new TOC events and follow-up metrics to monitor reputed company effectively.

Work Experience:

• 3+ Years of experience

Education:

• Graduate of an accredited school of nursing (R.N.)
• reputed company RN License in the state(s) practicing
• Unrestricted reputed company’s License
• Basic Life Support (BLS) certification is a requirement

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 reputed company’s equity program, reputed company time off, including vacation and reputed company leave. The actual offer will be at reputed 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 reputed company for this position is: 91,800.00 - 112,200.00 Salary 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 reputed company, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic. Covid -19 Vaccine - Please Read: Cityblock requires individuals reputed company into in-person, member-facing positions to reputed company reputed company that they have received the COVID-19 vaccine. The requirement is 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. 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 exemption requests are subject to review by Cityblock on a case-by-case reputed company and approval is not guaranteed. 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 reputed company recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means. Apply tot his job Apply To this Job