Resource RN - Pop Health - NC - REMOTE

Outreach to members while admitted inpatient or after inpatient or emergency department discharge to conduct focused transitions of care assessments. Outreach to case managers for members that are admitted inpatient to assist with discharge planning as needed. Complete self-efficacy and condition-specific screeners 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. 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. Triage referrals from the Population Health Partner for short term clinical interventions and chronic disease management.

Meet members in various community settings such as homes,shelters, or hospitals, serving as an extender of care team providers and performing tasks like administering injections, monitoring vital signs, and in-home medication reconciliation. Review charts and data signals for potential transition to higher level of complex care management. Facilitate follow ups and hand offs to care team as needed.

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.

Success Metrics

Timely outreach to members and hospital case managers for transitions of care support. Completion of focused transitions of care assessments, ensuring accurate medication reconciliation and follow up visits are scheduled. Identification and timely escalation of members requiring higher-intensity programs or behavioral health interventions. Completion of assigned queue tasks within established timelines. Efficient management of multiple short-term clinical assignments without compromising quality. Effective communication and collaboration with care team members, Population Health Partners, and community providers.

Job Requirements

Professional Experience & Knowledge

Education

Graduate of an accredited school of nursing (R. N.)

Experience

3+ years of experience Problem Solving: Strong critical thinker with sound clinical judgment who makes complex decisions independently and knows when to collaborate. Identifies system barriers to care and develops creative, practical solutions. Demonstrates a growth mindset and openness to innovative approaches to improve outcomes.

Communication: Strong written and verbal communicator across phone, text, virtual, and in-person settings. Comfortable using technology to engage members remotely. Applies Motivational Interviewing and Trauma-Informed Care principles to build trust.

Effectively translates clinical information for non-clinical audiences and actively listens to understand and address needs.

Behavioral Competencies

Member Advocate

Mission Driven: Balances competing priorities by choosing the path that best aligns with service to members and inclusive processes. Compassionate Care: Identifies and responds to member needs proactively and suggests improvements that enhance the member experience. Business Acumen: Applies understanding of government-funded care to make better recommendations and improve processes.

Team Builder

Collaboration: Adapts collaboration style to build understanding and bridge communication gaps and encourages others to share ideas. Team Effectiveness: Helps improve how the team works together through observations and feedback. Engaged Culture: Highlights others’ contributions and drives small but meaningful and inclusive actions to contribute to team morale, safety, and engagement.

Results Driver

Strategic Clarity: Helps peers stay aligned by translating broader goals into clear team action, identifies misalignment, and proposes solutions to bring clarity and focus. Proactive Approach: Spots gaps or roadblocks early and proposes ways around them, demonstrating resourcefulness and persistence even when projects are ambiguous or difficult. Accountability: Uses metrics and data to evaluate impact and refine their approach, holding self and others to reliably high standards.

Growth Agent

Development: Invests time in personal development that aligns with business needs and supports learning within the team by sharing knowledge or tools. Adaptability: Helps translate abstract or evolving strategies into actionable work informed by business context and pushes through discomfort to deliver results and learn in new territory. Innovation: Challenges assumptions thoughtfully and constructively and applies creative problem-solving to ambiguous or evolving work.

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:

85,000 - 91,000

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.