Hybrid RN: Field & Remote Transitions of Care

Cityblock Health; Worcester (MA); Hybrid; USD 95,000 - 105,000; Full time

Benefits offered by this job

Health insurance

Life insurance

Retirement benefits

Equity program

Paid time off

Job summary

Cityblock Health is seeking a Resource RN to provide nursing support for members with low- acuity, short-term needs. The role blends field and remote work (roughly 70% field, 30% remote) with task-based prioritization and coordination of care transitions.

The RN will perform medication reconciliation, behavior health screenings, and collaborate with care teams to determine the appropriate program intensity, while delivering virtual and in-person care as needed.

Qualifications

• Education: Graduate of an accredited school of nursing (R.N.)
• Experience: 3+ years of nursing experience

Responsibilities

• Outreach to members during inpatient stay or after discharge to support transitions of care.
• Coordinate with case managers for discharge planning for admitted members.
• Administer self-efficacy and condition-specific screeners (PHQ-9, GAD-7, AUDIT, DAST-10).
• Perform in-person clinical exams when appropriate and determine care placement with the team.
• Conduct comprehensive medication reconciliation and ensure proper chart documentation and coding.
• Triage referrals for short-term interventions and chronic disease management.
• Visit members in homes, shelters, or hospitals and assist with injections, vital signs, and home med reconciliation.
• Review charts/data signals to identify need for higher levels of care.
• Facilitate follow-ups and handoffs to the care team as needed.
• Use EHRs and scheduling platforms to document interactions and coordinate care resources.

Skills

Nursing

Clinical education

Care transitions

PHQ-9

GAD-7

AUDIT

DAST-10

Education

RN

Tools

Electronic health records

Job description

Cityblock Health is seeking a Resource RN to provide nursing support for members with low- acuity, short-term needs. The role blends field and remote work (roughly 70% field, 30% remote) with task-based prioritization and coordination of care transitions.

The RN will perform medication reconciliation, behavior health screenings, and collaborate with care teams to determine the appropriate program intensity, while delivering virtual and in-person care as needed.