Field-Based RN Case Manager — Care Coordination Specialist

CVS Health; Maryland Heights (MO); On-site; USD 73,000 - 156,000; Full time

Benefits offered by this job

Paid vacation time

Health insurance

401K match

Continuing education stipends

Flexible work environments

Leadership development

Job summary

Oak Street Health is seeking an RN, Case Manager for a field-based, on-site role in the Bronx area. You will collaborate with PCPs, care teams, and families to coordinate comprehensive care for complex patients, focusing on reducing avoidable admissions and optimizing resource use.

The role requires an active RN license and CCM certification (or plan to obtain within 12 months). Fluency in Spanish or other languages commonly spoken by our communities is required.

Qualifications

• Current RN license in assigned state; Bachelor degree in nursing preferred.
• CCM certification required or to be obtained within 12 months of hire unless candidate has 2–3 years of relevant care/case management experience.
• Fluency in Spanish or other languages spoken by communities we serve is required.

Responsibilities

• Manage an assigned caseload of complex patients in a value-based care environment, aiming to reduce admissions and readmissions.
• Own panel metrics for admission prevention, readmission prevention, and transitions of care.
• Lead and coordinate care across the team, ensuring accountability and follow‑through.
• Oversee transitions of care episodes, conduct assessments, and perform medication reconciliation with the PCP.
• Collaborate with PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and others to align goals and plans.
• Document key clinical assessments after admissions and participate in planning meetings.
• Lead in‑person interdisciplinary care planning meetings to coordinate patient care.
• Provide nursing assessments and patient education for chronic condition management and transitions of care.
• Educate patients and families, empowering them to participate in their care.

Skills

Bilingual (Spanish)

RN license

CCM certification

Care coordination

Discharge planning

Time management

Interdisciplinary collaboration

Travel to communities

Education

BSN preferred

Job description

Oak Street Health is seeking an RN, Case Manager for a field-based, on-site role in the Bronx area. You will collaborate with PCPs, care teams, and families to coordinate comprehensive care for complex patients, focusing on reducing avoidable admissions and optimizing resource use.

The role requires an active RN license and CCM certification (or plan to obtain within 12 months). Fluency in Spanish or other languages commonly spoken by our communities is required.