RN Assessment Nurse - Barnstable County - Hybrid

Cityblock; Barnstable (MA); Hybrid; USD 95,000 - 104,000; Full time

Benefits offered by this job

Health insurance

Retirement benefits

Equity program

Paid time off

Job summary

Cityblock Health in Massachusetts seeks an Assessment RN to complete MDS, conduct key screenings (PHQ9, GAD7, AUDIT, DAST10), and build initial member care plans. The role involves triage for behavioral health, collaborating with the care team, and addressing adherence during visits.

The position emphasizes strong clinical judgment, tech-enabled engagement, and motivational interviewing to support members in achieving health goals within a member-centered care model.

Qualifications

• Graduate of an accredited school of nursing (R.N.)
• 3+ years of experience
• Strong critical thinker with sound clinical judgment
• Identifies system barriers to care and develops creative, practical solutions
• Demonstrates a growth mindset and openness to innovative approaches to improve outcomes
• 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
• Effectively translates clinical information for non-clinical audiences and actively listens to understand and address needs

Responsibilities

• Explain Cityblock’s model of care to members, ensuring they understand the services available to them.
• Complete the Minimum Data Set (MDS) and/or comprehensive member assessments during the intake process.
• Conduct self efficacy and relevant condition specific screeners, including behavioral health assessments like PHQ9, GAD7, AUDIT, and DAST10.
• Triage members requiring behavioral health programming and conduct in person clinical exams when appropriate.
• Collaborate with the care team to assess if a member requires placement in a different program, whether a lower or higher intensity option is necessary.
• Develop an initial care plan with the member, clearly documenting any clinical concerns identified during the assessment that the member has declined to include.
• Focus on medication reconciliation during clinical visits, addressing adherence concerns and educating the member.
• Address contracted and company prioritized quality gaps, ensuring proper chart documentation and inclusion of necessary codes (ICD or CPT) for gap closure and risk stratification.
• Collect data
• Document member interactions
• Organize information
• Track tasks
• Communicate effectively with the team, members, and community resources.

Skills

RN

Critical thinking

Clinical judgment

Motivational Interviewing

Trauma-Informed Care

Strong communication

Education

Graduate of an accredited school of nursing (R.N.)

Job description

Job Description

The Assessment RN completes MDS and relevant screenings within assigned territory as scheduled to capture members’ clinical needs and meet regulatory requirements, and also works with members to create a comprehensive care plan that accurately reflects members’ needs and healthcare goals. Uses clinical judgment to escalation members with urgent clinical needs to appropriate departments as needed.

Responsibilities

• Explain Cityblock’s model of care to members, ensuring they understand the services available to them.
• Complete the Minimum Data Set (MDS) and/or comprehensive member assessments during the intake process.
• Conduct self efficacy and relevant condition specific screeners, including behavioral health assessments like PHQ9, GAD7, AUDIT, and DAST10.
• Triage members requiring behavioral health programming and conduct in person clinical exams when appropriate.
• Collaborate with the care team to assess if a member requires placement in a different program, whether a lower or higher intensity option is necessary.
• Develop an initial care plan with the member, clearly documenting any clinical concerns identified during the assessment that the member has declined to include.
• Focus on medication reconciliation during clinical visits, addressing adherence concerns and educating the member.
• Address contracted and company prioritized quality gaps, ensuring proper chart documentation and inclusion of necessary codes (ICD or CPT) for gap closure and risk stratification.
• Collect data
• Document member interactions
• Organize information
• Track tasks
• Communicate effectively with the team, members, and community resources.

Qualifications

• Graduate of an accredited school of nursing (R.N.)
• 3+ Years of experience
• 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.
• 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.

Benefits and 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: $95,000 - $104,000

Equal Opportunity Employer

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

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.

Company Overview

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.