Resource RN - Pop Health - NC - REMOTE

Cityblock Health; Raleigh (NC); Remote; USD 71,000 - 91,000; Full time

Benefits offered by this job

Health insurance

Life insurance

Retirement benefits

Equity program

Paid time off

Vacation and sick leave

Job summary

Cityblock Health is seeking a seasoned RN for a fully remote role in North Carolina. Candidates must hold an active NC RN license or Compact license allowing NC practice.

The position focuses on transitions of care, inpatient/outpatient coordination, and behavioral health screening to support members in their homes and communities. You will collaborate with care teams, perform medication reconciliation, document in EHRs, and ensure timely follow-ups.

Qualifications

• Graduate of an accredited nursing program with RN licensure.
• Minimum 3 years of clinical experience.
• Strong clinical judgment and independent decision-making.
• Excellent written and verbal communication.
• Familiarity with Motivational Interviewing and Trauma-Informed Care.
• Ability to work remotely and coordinate across care teams.

Responsibilities

• Outreach to members during inpatient stay or after discharge for transitions of care assessments.
• Collaborate with case managers to coordinate discharge planning.
• Conduct self-efficacy and behavioral health screeners (PHQ-9, GAD-7, AUDIT, DAST-10).
• Review charts, perform medication reconciliation, and ensure ICD/CPT coding accuracy.
• Triage referrals and support short-term clinical interventions.
• Meet members in homes, shelters, or hospitals and assist with injections and vital signs.
• Utilize EHRs and scheduling tools to document interactions and track tasks.

Skills

RN license

Transitions of Care

Behavioral health tools

Motivational Interviewing

Trauma-Informed Care

EHR proficiency

Education

Nursing degree (RN)

Tools

EHR systems

Job description

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.

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 & KnowledgeEducation: Graduate of an accredited school of nursing (R.N.)Experience: 3+ years of experienceProblem 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. The expected salary range for this position is:$71,000.00 - $90,500.00 Annual

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.