About the role:

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.

Engagement

• Receives members from engagement and care team
• Describe program expectations (e.g., length) and goals to members

Assess/Intake

• Complete self-efficacy and relevant condition-specific screeners with members
• 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)

Case Review and Care Planning

• Prep and actively participate in case conference and leading discussion as appropriate
• Develop care plans with the members, collaborate with Community Health Partners on social needs as needed

Clinical Visits and Follow-Up

• Regular check-ins with member as guided by program
• Follow-up on routine therapeutic interventions by internal or external providers
• Address and respond to member needs and delegate tasks in timely fashion
• Collaborate on a panel of members assigned to your care team to provide clinical support, including health maintenance, chronic disease management and co-occurring psychiatric disorder support
• 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
• Support members in achieving their care plan goals

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:

• Active, unrestricted RN license in the state in which you are seeking employment with Cityblock
• You have 3 years of experience providing clinical services to adult and pediatric individuals with co-occurring chronic medical and behavioral health conditions
• Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and care coordination team members
• Familiarity and willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals and rehab centers)

Job Type: Full-time

Pay: $79,000.00 - $87,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Mileage reimbursement
• Paid time off
• Parental leave
• Referral program
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• Acute care
• Long term care
• Telehealth

Experience:

• Case management: 1 year (Required)
• Behavioral health: 1 year (Required)

License/Certification:

• RN License in NC (Required)

Ability to Relocate:

• Fayetteville, NC: Relocate before starting work (Required)

Work Location: Multiple locations