RN Case Manager, Transitions of Care

Position Overview

• Location Type: Onsite
• Job Type: Full-time
• Salary: $91,800.00 - $105,000.00

Cityblock's Transition of Care (TOC) program assists members in safely transitioning from acute care and hospital settings back into the community. The TOC Registered Nurse Care Manager (RNCM) collaborates with hospital case managers to assess member needs and conduct discharge visits (in-home or virtual) with members and providers. The TOC RNCM also handles referrals, triages member needs, and provides clinical education to prevent hospital readmissions.

Requirements

• Graduate of an accredited school of nursing (R.N.)
• 3+ Years of experience

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.

Company Information

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.

Benefits:

• Health insurance
• Life insurance
• Retirement benefits
• Participation in the company’s equity program
• Paid time off, including vacation and sick leave

COVID-19 Vaccine Policy: Cityblock requires individuals hired into in-person, member-facing positions to provide proof that they have received the COVID-19 vaccine. This 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 the community.

Location: Virginia (Fairfax, Loudon, Arlington, & Alexandria City, Manassas Park City, Manassas City, Prince William, Fairfax City, Falls Church City)