RN Case Manager - Montgomery County

Job Description: The RN Care Manager (RNCM) manages a panel of clinically complex members to support impactable clinical programs, quality gap initiatives and ED and IP utilization. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs while moving members toward clinical program and pathway graduation. The RNCM coordinates closely with both the integrated Cityblock Care Team as well as external providers and community partners. Key Responsibilities Receives members from the engagement and central teams, clearly communicating program expectations, including duration and goals. Completes self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs. Refers members to behavioral health programs as needed. Conducts in-person clinical examinations when appropriate and collaborates with care team members to determine member placement in programs of varying intensity. Prepares for and actively participates in case conferences, leading discussions when necessary. Develops a care plan in collaboration with the member, addresses social needs with the support of the Community Health Partner and supports members in achieving their care plan goals through coordinated and comprehensive care efforts. Conducts regular clinical visits and follow-ups per clinical program and pathway guidelines, monitoring routine therapeutic interventions and addressing member needs promptly. Collaborates with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support. Performs medication reconciliation, administration, compliance, and education as part of member care. Addresses quality gaps prioritized by the contracted company and ensures thorough chart documentation and coding (ICD or CPT) to validate gap closures. Utilizes care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources. Success Metrics Members have an active care plan and are enrolled into appropriate clinical programs based on identified needs. Support members in progressing toward and completing care plan goals and program graduation. Closure of quality gaps for members on assigned panel. Completion of accurate and timely documentation. Effective collaboration with interdisciplinary care team members. Effective coordination of care with external providers and community resources. Support members through inpatient and ED transitions of care. 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. 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. Benefits and Compensation health insurance life insurance retirement benefits participation in the company’s equity program paid time off, including vacation and sick leave The expected salary range for this position is: $95,000 - 102,000 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. About Cityblock 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. 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. We 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. #J-18808-Ljbffr Cityblock Health