Field-Based RN Case Manager: Care Coordination Leader

Oak Street Health; Allentown (Lehigh County); On-site; USD 61,000 - 130,000; Full time

Benefits offered by this job

Sign-on bonus

Health insurance

401K match

Job summary

Oak Street Health seeks an experienced RN, Case Manager to lead complex patient care coordination in a field-based role across PA communities. You will drive care continuity with PCPs and interdisciplinary teams, reduce avoidable hospital utilization, and guide transitions of care through structured assessments and patient education.

Eligible candidates may receive a sign-on bonus. Must have an active RN license in the state and CCM or plan to obtain within 12 months; 6–8 years of nursing

Qualifications

• Current RN license in the assigned state is required; Bachelor degree in nursing preferred.
• Minimum of 6–8 years nursing experience.
• Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire, unless candidate has 2–3 years of relevant care/case management experience.
• 2+ years experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health preferred.
• Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources.

Responsibilities

• Manages an assigned caseload of complex patients in a value-based care environment, focusing on reducing admissions and medical utilization.
• Accountable for panel metrics in admission and readmission prevention and transitions of care.
• Owns overall care coordination for assigned patients, serving as the primary contact across the care team.
• Manage transitions of care episodes, including structured assessments and medication reconciliation on behalf of the PCP.
• Collaborates with PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other team members to plan and progress care.
• Lead in-person interdisciplinary care planning meetings to ensure effective coordination.
• Perform timely nursing assessments and provide patient education for chronic condition management and transitions of care.
• Educate patients and families, advocating for their needs and empowering their care.

Skills

RN license

Nursing experience

Motivational interviewing

Patient activation

Travel readiness

US work authorization

Education

Bachelor degree in nursing

Certified Case Manager (CCM) required or within 12 months

Job description

Oak Street Health seeks an experienced RN, Case Manager to lead complex patient care coordination in a field-based role across PA communities. You will drive care continuity with PCPs and interdisciplinary teams, reduce avoidable hospital utilization, and guide transitions of care through structured assessments and patient education.

Eligible candidates may receive a sign-on bonus. Must have an active RN license in the state and CCM or plan to obtain within 12 months; 6–8 years of nursing