Field-Based RN Case Manager: Lead Care Coordination

Oak Street Health, part of CVS Health; Indianapolis (IN); On-site; USD 61,000 - 130,000; Full time

Benefits offered by this job

Sign-on bonus

Health insurance

Vision and dental benefits

401K match

Job summary

Oak Street Health in Indianapolis is seeking an experienced RN, Case Manager to lead care coordination for complex patients in a value-based care model. This field-based, on-site role partners with PCPs and an interdisciplinary team to prevent admissions and optimize transitions of care.

You will manage an assigned panel, document assessments, educate patients, and ensure timely follow-up with an emphasis on patient activation and quality outcomes.

Qualifications

• Current RN license in assigned state (Indiana).
• CCM certification required or willing to obtain within 12 months of hire.
• 2+ years of nursing experience in transitional care, care coordination, discharge planning, or home health preferred.
• Strong communication, time management, and ability to navigate community resources.
• Willingness to travel within Oak Street Health communities; access to reliable transportation.

Responsibilities

• Manage an assigned caseload of complex patients in a value-based care setting.
• Drive admissions/readmission prevention and transitions of care metrics.
• Own overall care coordination and be primary point of contact for the care team.
• Complete structured clinical assessments post-discharge and reconcile medications.
• Collaborate with PCPs, families, social workers, and behavioral health specialists.
• Document visits in the EHR according to standards and ensure care plan progression.
• Lead in-person interdisciplinary care planning meetings for patient management.
• Provide nursing assessments and patient education on chronic conditions and transitions of care.

Skills

Care coordination

Patient education

Interdisciplinary collaboration

Motivational interviewing

Time management

Documenting in EHR

Patient advocacy

Education

Bachelor's degree in Nursing

Job description

Oak Street Health in Indianapolis is seeking an experienced RN, Case Manager to lead care coordination for complex patients in a value-based care model. This field-based, on-site role partners with PCPs and an interdisciplinary team to prevent admissions and optimize transitions of care.

You will manage an assigned panel, document assessments, educate patients, and ensure timely follow-up with an emphasis on patient activation and quality outcomes.