RN Assessment Nurse - Barnstable County - Hybrid

Cityblock Health; Massachusetts; On-site; USD 95,000 - 104,000; Full time

Benefits offered by this job

Health insurance

Life insurance

Retirement benefits

Equity program

Job summary

Cityblock Health is seeking an Assessment RN to complete MDS and relevant screenings within the assigned territory, capturing members’ clinical needs and meeting regulatory requirements. You will work with members to craft a comprehensive care plan reflecting their needs and goals, escalating urgent cases as needed.

The role emphasizes medication reconciliation, collaboration with the care team, and effective use of EHRs to document care and track tasks.

Qualifications

• Graduate of an accredited school of nursing (R.N.).
• 3+ years of RN experience.
• Strong critical thinker with sound clinical judgment.
• Experience using Motivational Interviewing and Trauma-Informed Care.

Responsibilities

• Explain Cityblock’s model of care to members.
• Complete the Minimum Data Set (MDS) and comprehensive assessments during intake.
• Conduct self-efficacy and screeners including 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 program intensity needs.
• Develop an initial care plan with the member and document clinical concerns.
• Focus on medication reconciliation and educating the member on adherence.
• Address quality gaps with proper chart documentation and codes (ICD/CPT).
• Use care facilitation, EHRs, and scheduling platforms to collect data, document interactions, organize information, track tasks.

Skills

Clinical assessment

Documentation

Motivational Interviewing

Trauma-Informed Care

Education

Registered Nurse (RN) degree

Tools

Electronic Health Records (EHR)

Scheduling platforms

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 escalates members with urgent clinical needs to appropriate departments as needed.

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 escalates 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.
• Use care facilitation, electronic health records, and scheduling platforms to:
• Collect data
• Document member interactions
• Organize information
• Track tasks
• Communicate effectively with the team, members, and community resources.

Work Experience

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

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 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:
$95,000 - $104,000

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.