Company: Oak Street Health
Title: RN, Case Manager
Location
- Lawncrest Clinic – 3621 Aramingo Ave, Philadelphia, PA 19134
- Aramingo Clinic – 5843 Rising Sun Ave, Philadelphia, PA 19120
Subject to adjustment based on clinic needs.
Eligible candidates may receive a sign‑on bonus as part of the offer package.
Role Description
In partnership with the primary care provider (PCP), the RN, Case Manager is the lead for care management activities, drives care coordination and collaborates with interdisciplinary teams to ensure care continuity for complex patients. This role focuses on preventing avoidable admissions, driving efficient resource utilization, and ensuring effective team‑based care. It is a field‑based, in‑person/on‑site role, requiring strong relationships between patients, providers and care team members.
Core Responsibilities
- Manage an assigned caseload of complex patients in a value‑based care environment, focusing on reduced admissions, readmissions, and medical utilization.
- Accountable for panel metric performance in admission prevention, readmission prevention, and transitions of care metrics.
- Own overall care coordination for assigned patients, functioning as the primary point of contact and ensuring alignment, accountability, and follow‑through across the care team.
- Manage transitions of care episodes for patients on their panel, including timely completion of structured clinical assessments to identify post‑discharge needs, medication reconciliation on behalf of the PCP, and addressing identified needs directly or via collaboration with other team members.
- Collaborate with the patient’s PCP, family/caregiver, social worker, behavioral health specialists, and other care team members to evaluate the individual’s needs, goals, and plan of action and ensure care plan progression.
- Ensure timely documentation of key clinical assessments after admissions, while balancing in‑center care team planning meetings.
- Lead in‑person interdisciplinary care planning meetings to ensure effective care coordination and management between provider visits.
- Perform timely nursing assessments and provide patient education for chronic condition management and transitions of care.
- Educate patients and families, empowering them in their care, and advocating for their needs.
- Document visits in electronic health record according to internal standards.
- Other duties as assigned.
Qualifications
- Fluency in Spanish or other languages spoken in the communities served, strongly preferred.
- Current RN license in the assigned state is required; bachelor’s 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 the 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 strongly preferred.
- Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources.
- Flexible and positive attitude.
- Comfort with ambiguity and change.
- High emotional intelligence with the ability to evaluate and perceive a situation from multiple lenses and understand various perspectives in problem resolution.
- Access to reliable transportation and ability to travel throughout the communities served.
- US work authorization.
- Someone who embodies being Oaky.
What does being Oaky look like?
- Radiating positive energy.
- Assuming good intentions.
- Creating an unmatched patient experience.
- Driving clinical excellence.
- Taking ownership and delivering results.
- Being relentlessly determined.
Benefits
- Mission‑focused career impacting change and measurably improving health outcomes for Medicare patients.
- Paid vacation, sick time, and 401(k) match options.
- Health, vision, and dental benefits.
- Opportunities for leadership development and continuing education stipends.
- New centers and flexible work environments.
- Opportunities for high levels of responsibility and rapid advancement.
Employment Details
Anticipated Weekly Hours: 40
Time Type: Full time
Pay Range: $66,575 – $142,576 (base salary)
This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay.
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Application window closes on 04/30/2026.