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 ensure 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
Job Requirements
Professional Experience & Knowledge
Education : Graduate of an accredited school of nursing (R.N.)
Experience: 3+ Years of experience
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 app
Benefits
Health insuranceRemote work options
Additional Information
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.
This role is a Hybrid Role supporting our Triad area of North Carolina.
Cityblockhealth · Triad, NC