Resource RN - Pop Health - NC - REMOTE

Job Description: This is a 100% remote position. Candidates must hold an active North Carolina RN license or a Compact RN license that permits practice in North Carolina. Familiarity with North Carolina communities, healthcare resources, and the populations served is preferred The Resource RN provides nursing support to members with low-acuity, short-term clinical needs. This role does not carry an assigned member panel; instead, the Resource RN works from a task-based queue to address targeted clinical needs. Responsibilities include providing clinical education, delivering focused interventions, and supporting care transitions following inpatient or emergency department visits. Care is delivered virtually and in person, as appropriate. The Resource RN also conducts chart reviews and evaluates clinical data to identify members who may require higher levels of care management or short-term clinical intervention. Key Responsibilities 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. 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: 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. 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. Our 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 Medical Practice, P.A.