Field RN Case Manager — Complex Care & Transitions

8350 Oak Street Health MSO LLC; Kentucky; On-site; USD 73,000 - 156,000; Full time

Benefits offered by this job

Health insurance

Vision benefits

Dental benefits

Paid time off

Sick leave

401K match

Job summary

Oak Street Health in New York area seeks an RN, Case Manager to lead care coordination for complex patients in a value‑based care setting. This field‑based, on‑site role partners with PCPs and interdisciplinary teams to prevent avoidable admissions and ensure smooth transitions of care.

You will manage a panel, conduct structured assessments, document in EHR, educate patients, and attend in‑person care planning meetings while traveling across communities OSH serves.

Qualifications

• Current RN license in assigned state is required.
• CCM certification required or willingness to obtain within 12 months of hire.
• 2+ years in transitional nursing, care coordination or discharge planning preferred.
• Strong communication and collaboration with PCPs and care teams.

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 and document visits in EHR.
• Educate patients and families, supporting chronic condition management and transitions of care.

Skills

Spanish fluency

Motivational interviewing

Time management

Care coordination

Education

RN license

Bachelor's in Nursing preferred

Job description

Oak Street Health in New York area seeks an RN, Case Manager to lead care coordination for complex patients in a value‑based care setting. This field‑based, on‑site role partners with PCPs and interdisciplinary teams to prevent avoidable admissions and ensure smooth transitions of care.

You will manage a panel, conduct structured assessments, document in EHR, educate patients, and attend in‑person care planning meetings while traveling across communities OSH serves.