Job Description:

The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy.

This role in Monday-Friday: 8:30am-5pm, Hybrid Role Virtual/Community

Covering Lucas County

Responsibilities:

• Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals.
• Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs.
• Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity.
• Prepare for and actively participate in case conferences, leading discussions when necessary.
• Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner.
• Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly.
• Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support.
• Perform medication reconciliation, administration, compliance, and education as part of member care.
• Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures.
• Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources.
• Support members in achieving their care plan goals through coordinated and comprehensive care efforts.

Work Experience:

• 3+ Years of experience

Education:

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

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:

$90,000-$96,000 Annually

We value 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.

Covid -19 Vaccine - Please Read:

We require individuals hired into in-person, member-facing positions to provide proof that they have received the COVID-19 vaccine.

The requirement is based on the safety and effectiveness of the vaccine in protecting against COVID-19, and our shared responsibility for the health and safety of members, colleagues, and community.

Any individuals subject to this requirement may submit for consideration a request to be exempted from the requirement (based on a valid religious or medical reason) on forms to be provided by us. Such exemption requests are subject to review by us on a case-by-case basis and approval is not guaranteed.

Medical Clearance (for Member-Facing Roles):

You must complete our 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. We will not pay fees associated with resumes presented through unsolicited means.

About Us:

We are 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 team, and every 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 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.