RN Care Manager - Chronic Disease & Behavioral Health

Cityblock Health; Greensboro (NC); On-site; USD 90,000 - 95,000; 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 seeks an experienced Registered Nurse Care Manager to oversee a panel of members with chronic diseases and behavioral health needs. You will collaborate to create and monitor care plans, coordinating with providers and the Community Health Partner to advocate for patients and drive outcomes.

You will conduct assessments, document care, and participate in case conferences while supporting timely clinical visits and medication management in a dynamic team setting.

Qualifications

• Active, unrestricted RN license in the state where you seek employment with Cityblock.
• 3+ years of clinical services experience for adults/geriatrics with co-occurring chronic medical and behavioral health conditions.
• Willingness to travel within your community for home-based member visits and care coordination across healthcare systems.

Responsibilities

• Receive members from the engagement and care team, communicating program expectations, duration, and goals.
• Complete self-efficacy and condition-specific screeners (PHQ-9, GAD-7, AUDIT, DAST-10) to identify behavioral health needs.
• Conduct in-person clinical examinations and collaborate with the care team for program intensity placement.
• Prepare for and participate in case conferences, leading discussions when needed.
• Develop care plans with the member and address social needs with support from Cityblock’s Community Health Partner.
• Conduct regular clinical visits and follow-ups per program guidelines, monitoring therapy and addressing needs promptly.
• Collaborate with the care team to support a panel of assigned members in health maintenance and chronic disease management.
• Perform medication reconciliation, administration, compliance, and education as part of member care.
• Address quality gaps prioritized by the contracted company and ensure chart documentation and coding (ICD/CPT) to close gaps.
• Use EHRs and scheduling platforms to gather data, document interactions, organize information, track tasks, and communicate with team members and community resources.
• Support members in achieving care plan goals through coordinated, comprehensive care efforts.

Skills

RN license

Care coordination

Documentation/writing

Interdisciplinary teamwork

Home visits travel

Wound assessment

Phlebotomy

Education

RN (Graduate of accredited nursing school)

Tools

EHR

Care facilitation tools

Job description

Cityblock Health seeks an experienced Registered Nurse Care Manager to oversee a panel of members with chronic diseases and behavioral health needs. You will collaborate to create and monitor care plans, coordinating with providers and the Community Health Partner to advocate for patients and drive outcomes.

You will conduct assessments, document care, and participate in case conferences while supporting timely clinical visits and medication management in a dynamic team setting.