RN Assessment Nurse - Barnstable County - Hybrid

Cityblock Medical Practice, P.A.; Massachusetts; 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 is seeking an Assessment RN to complete MDS and comprehensive member assessments, develop care plans, and coordinate with the care team to address urgent clinical needs. You will perform behavioral health screenings, ensure accurate documentation, and focus on medication reconciliation during visits.

The role emphasizes collaboration with the team, strong clinical judgment, and effective use of care facilitation tools, EHRs, and scheduling platforms.

Qualifications

• RN, registered nurse, with licensure in good standing.
• Minimum 3+ years of nursing experience in a relevant setting.
• Strong critical thinking and clinical judgment for complex decisions.

Responsibilities

• Explain Cityblock’s care model to members and outline available services.
• Complete MDS or comprehensive assessments during intake.
• Perform self-efficacy and condition-specific screens (PHQ9, GAD7, AUDIT, DAST10).
• Triage behavioral health needs and conduct in-person exams when appropriate.
• Collaborate with care team to determine appropriate program placement and care intensity.
• Develop initial care plans with members and document concerns.
• Prioritize medication reconciliation and address adherence during visits.
• Ensure proper charting with ICD/CPT codes for gap closure and risk stratification.
• Use EHRs and scheduling tools to collect data, document interactions, organize information, track tasks, and communicate with the team.

Skills

Critical thinking

Communication

Motivational Interviewing

Trauma-Informed Care

Education

Registered Nurse (RN)

Tools

Electronic Health Records

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 elevate 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.

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 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.

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.

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.