Jobs
>
Chicago

    Care Coordinator, Transitions of Care - Chicago, United States - Cityblock

    Cityblock
    Cityblock Chicago, United States

    6 days ago

    Default job background
    Description

    About Us:


    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 arein their homes, in their community, and in our Hubs.

    You 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.


    About the Role:


    Cityblock's Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community.

    As a TOC Care Coordinator,, you will reach out to members to schedule post-discharge visits, provide care coordination and drive engagement to help ensure that members do not return to the hospital.


    Essential job responsibilities:
    Engagement

    Receive assignment of members from TOC team

    Reach out to member/caregiver to schedule post-discharge visit; describe the TOC program expectations and goals

    Assessments/Intake

    Complete assessments following protocols and as needed by the TOC Registered Nurse Care Manager (TOC RNCM)

    Case Review and Care Planning

    Support the TOC RNCM during discharge planning

    Partner with the TOC RNCM to develop post-discharge care plans that address identified needs and barriers to support a smooth recovery

    Support members in achieving their care plan goals

    Bring preliminary goals and identified resources to members to address social and care coordination needs

    Work with members to address goals in care plans and coach to completion

    Focus on members' goals, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs

    Participate in case conferences upon member discharge to discuss 30-day readmission mitigation plan

    Collaborate with TOC RNCM for hand-off to longitudinal care at conclusion of the TOC program

    Collaborate with TOC team to determine need for escalation of member care

    Follow-up

    Weekly check-ins with members to follow-up on post-discharge care plan needs and progress

    Provide care coordination (e.g., benefits, social needs, external care) with the member/caregiver, internal care team and external providers

    Provide routine non-clinical education on preventative care topics

    Address and respond to member needs and delegate tasks in timely fashion

    Meet with members in the community (home, SNF, IRF, shelter, hospital) as needed, including as an extender of the care team for non-clinical needs

    Complete screenings for emerging needs

    Refers members to the TOC RNCM for clinical needs, while including other internal collaborators as necessary (e.g., pharmacy team, Behavioral Health Team, Mobile Integrated Care Team)

    Support loop closure on internal referrals

    Operations and Reporting

    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

    Track TOC metrics for assigned members and log new TOC events and accompanying follow-up metrics.


    Requirements for the Role:
    HS Diploma

    At least 1-2 years of experience in community care or care coordination required

    Unrestricted Driver's License and vehicle for daily use

    Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)

    Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management

    Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation

    Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner

    Versed in Motivational Interviewing and Trauma Informed Care principles

    Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members

    Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members' care and health

    Growth and learning mentality, ability to think outside the box, go outside the bounds of "traditional" responsibilities

    Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities

    What We'd Like From You:
    A resume and/or LinkedIn profile

    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.

    We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.

    #J-18808-Ljbffr
  • Option Care Health

    Clinical Care Transition Educator

    1 week ago

    Option Care Health Chicago, United States

    Extraordinary Care. Extraordinary Careers. · With the nation's largest home infusion provider, there is no limit to the growth of your career. · Option Care Health, Inc. is the largest independent home and alternate site infusion services provider in the United States. With over ...

  • Option Care Health

    Clinical Care Transition Educator

    10 hours ago

    Option Care Health Chicago, IL, United States

    Extraordinary Care. Extraordinary Careers. · With the nation's largest home infusion provider, there is no limit to the growth of your career. · Option Care Health, Inc. is the largest independent home and alternate site infusion services provider in the United States. With over ...

  • Oak Street Health

    Transitional Care Manager Social Worker

    1 week ago

    Oak Street Health Chicago, United States

    Role Description: · Oak Street Health takes a team-based approach to providing outstanding patient care. The Transitional Care Manager - SW (TCM-SW) is an integral part of the team. The TCM-SW is the primary member of the Oak Street care team and facilitator of interdisciplinary ...

  • Hektoen Institute LLC

    Transitional Corrections Specialist

    1 week ago

    Hektoen Institute LLC Chicago, United States

    The CCHIP Transitional Corrections Specialist (TCS) will provide support to Adult and Corrections Clinic populations. The Transitional Corrections Specialist efforts will include communication and documentation of interactions with individuals living with HIV who are currently en ...

  • Trilogy Behavioral Healthcare

    Team Leader

    1 week ago

    Trilogy Behavioral Healthcare Chicago, United States

    Overview: · **$62, ,000 /Yr.** · **Schedule: Monday - Friday; 8:00 am - 4:30 pm** · The Hybrid Transition and Community Support Team will assist Class Members in transitioning from nursing facilities to the community and provide support services to Class Members post-transition i ...

  • RUSH University Medical Center

    Manager Rn Care Management

    6 days ago

    RUSH University Medical Center Chicago, United States

    **Location**:Chicago, IL · **Hospital**:RUSH University Medical Center · **Department**:MHN Primary Care Case Mgmt · **Work Type**:Full Time (Total FTE between 0. 9 and 1. 0) · **Shift: Shift 1** · **Work Schedule**:8 Hr · Summary: · The Manager RN, Care Management has specialize ...

  • Sonia Shankman Orthogenic School

    Transition Assistant

    11 hours ago

    Sonia Shankman Orthogenic School Chicago, United States

    **Join a therapeutic day school with wonderful students and great colleagues, offering small class sizes and caseloads, commitment to professional growth, competitive salary, comprehensive benefits and high vaccination rates among staff and students. We follow the latest IDPH and ...

  • Trilogy Behavioral Healthcare

    Transition Coordinator

    3 days ago

    Trilogy Behavioral Healthcare Chicago, United States

    Overview: · **$ /Hr.** · **Schedule: Monday - Friday; 8:00 am - 4:30 pm** · **$4,000 sign-on bonus** · **(This position requires a vehicle)** · The Transition Coordinator will work with Williams and Colbert Class Members to support safe transition from nursing facilities to livin ...

  • Hueman PE Talent Solutions

    Care Manager

    1 week ago

    Hueman PE Talent Solutions Chicago, United States

    The Care Manager serves as an integral part of the care team. The Care Manager will actively manage an assigned set of patients who are identified to be at high risk for avoidable and unnecessary utilization of hospital/system resources. The Care Manager will provide services to ...

  • Association House of Chicago

    Registered Nurse

    11 hours ago

    Association House of Chicago Chicago, United States

    **ABOUT ASSOCIATION HOUSE OF CHICAGO** · Founded in 1899 as one of Chicago's original settlement houses, Association House has a 122-year history of meeting the most pressing needs of those in the communities we serve. Today, we provide comprehensive, collaborative and effective ...

  • Ignite Org

    Belfort House Case Manager, Full-time

    1 week ago

    Ignite Org Chicago, United States Full time

    **Salary: $46,000/year** · Function: Responsible for working as a team member to establish and maintain the collaborative and positive tenor of the residential team. Responsible for the direct care of program youth housed within Belfort House. Demonstrates an understanding of and ...

  • University of Chicago Medicine

    Social Worker Nephrology

    3 days ago

    University of Chicago Medicine Chicago, United States

    **About the Department** · The Section of Nephrology in the Department of Medicine is comprised of twenty-two faculty members, one PhD scientist, and ten postdoctoral fellows in training devoted to a mission of excellence in patient care, education and research. The Section carri ...

  • Trissential

    Agile Coach

    1 week ago

    Trissential Chicago, United States

    Overview · Trissential is a trusted partner for end-to-end quality services and management consulting. As a part of our parent company Expleo, we have a footprint in 30+ countries. Our Mission is to have a positive impact on every person who interacts with Trissential. Clients lo ...

  • Humboldt Park Health

    Supervisor, Care Management

    1 day ago

    Humboldt Park Health Chicago, United States

    **Position Summary**: · Supervises the timely coordination of quality health care services to meet patient specific healthcare needs and services. Provides coaching and training of team members: includes utilization management, discharge planning, and quality monitoring. Ensures ...

  • University of Illinois

    Medical Social Consultant

    4 days ago

    University of Illinois Chicago, United States

    **Medical Social Consultant (Medical / Surgical Social Worker) - Health Social Work** · **Hiring Department**: Health Social Work · **Location**: Chicago, IL USA · **Requisition ID**: · **Work Schedule**:Monday - Friday 9:00 am - 5:00 pm · **Posting Close Date**: 5/24/2024 · **P ...

  • Trilogy Behavioral Healthcare

    House Manager

    6 days ago

    Trilogy Behavioral Healthcare Chicago, United States

    Overview: · **$ $21.81 /Hr.** · **Thursday, Friday, & Saturday 7:00 pm - 7:00 am (Overnight)** · The House Manager has overall responsibility for clients living in the residential program during their shift. They will provide direct clinical services for the clients in order to a ...

  • Belhaven Nursing & Rehabilitation Center

    Admissions Concierge

    1 week ago

    Belhaven Nursing & Rehabilitation Center Chicago, United States

    **We are looking for an Admissions Concierge** · **Belhaven values quality care as well as a productive, rewarding workplace culture.** · **Our comprehensive benefit package includes Excellent Pay, Tuition Reimbursement, Paid Vacation Time, Paid Sick Time, Group Health Insurance, ...

  • Legacy Healthcare

    Hospital Liaison

    11 hours ago

    Legacy Healthcare Chicago, United States

    Are you looking for a rewarding career in Skilled Nursing? We are currently searching for a Hospital Liaison to join our friendly, caring and supportive team · **Legacy Healthcare** is rapidly growing and our team is looking to invest in a Hospital Liaison by providing opportunit ...

  • South Shore Rehabilitation

    Activity Aide

    1 week ago

    South Shore Rehabilitation Chicago, United States

    Activity Aide · Part-time · Experience individualized care at an Extended Care affiliated facility. Each facility's highly skilled clinical and therapy teams are well-versed in delivering specialized services that are centered around your specific needs, interests, and capabiliti ...

  • Grasmere Place

    Receptionist

    1 day ago

    Grasmere Place Chicago, United States

    Receptionist · Experience individualized care at an Extended Care affiliated facility. Each facility's highly skilled clinical and therapy teams are well-versed in delivering specialized services that are centered around your specific needs, interests, and capabilities. This stea ...