Field-Based RN Case Manager: Care Coordination & Transitions

8350 Oak Street Health MSO LLC; University Heights (OH); On-site; USD 61,000 - 130,000; Full time

Benefits offered by this job

Paid time off

401K match

Medical, dental, vision

Job summary

Oak Street Health in University Heights is seeking an RN, Case Manager to lead care coordination for complex patients in a value‑based care setting. The field‑based role partners with PCPs, interdisciplinary teams, and families to prevent admissions and ensure smooth transitions of care.

Responsibilities include managing a caseload, owning care coordination, leading in‑person care planning meetings, conducting timely nursing assessments, educating patients, and documenting visits in the EHR.

Qualifications

• Current RN license in assigned state; Bachelor’s in nursing preferred.
• CCM certification required, or willingness to obtain within 12 months.
• 2+ years in transitional nursing, care coordination, discharge planning, or home health.
• Strong skills in motivational interviewing, patient activation, and time management.

Responsibilities

• Manages an assigned caseload of complex patients in a value-based care environment.
• Owns overall care coordination for assigned patients and acts as primary contact.
• Lead in-person interdisciplinary care planning meetings for effective coordination.
• Conduct timely nursing assessments and provide patient education for chronic care.
• Document visits in the EHR according to internal standards.
• Coordinate transitions of care, including medication reconciliation for PCP.
• Collaborate with PCP, family, social worker, and care team to align plans.
• Educate patients and families and advocate for their needs.

Skills

Care coordination

Nursing

Patient education

Motivational interviewing

Time management

Education

RN license

CCM certification

Tools

EMR / EHR

Job description

Oak Street Health in University Heights is seeking an RN, Case Manager to lead care coordination for complex patients in a value‑based care setting. The field‑based role partners with PCPs, interdisciplinary teams, and families to prevent admissions and ensure smooth transitions of care.

Responsibilities include managing a caseload, owning care coordination, leading in‑person care planning meetings, conducting timely nursing assessments, educating patients, and documenting visits in the EHR.