RN Care Manager - Field-Based Medicare Care Coordination

CVS Health; Indianapolis (IN); On-site; USD 60,522 - 129,615; Full time

Benefits offered by this job

Health insurance

Vision and dental benefits

Paid time off

401K match

Job summary

Oak Street Health in Indianapolis is hiring an RN Case Manager to lead care management for complex patients within a value-based care model. You will drive care coordination with the PCP, social worker, and care team to ensure continuity of care and reduce avoidable admissions.

This field-based role requires timely nursing assessments, medication reconciliation, transitions of care, and thorough documentation in the EHR.

Qualifications

• Current RN license in the assigned state is required; Bachelor degree in nursing preferred.
• CCM certification required or willingness to obtain within 12 months of hire.
• 2+ years experience in transitional nursing, care coordination, discharge planning, or home health preferred.
• Demonstrated skill in motivational interviewing and patient activation.
• Access to reliable transportation and ability to travel throughout the communities OSH serves.
• US work authorization.

Responsibilities

• Manages an assigned caseload of complex patients in a value-based care environment to reduce admissions and readmissions.
• Owns overall care coordination for assigned patients and acts as primary point of contact for the care team.
• Manage transitions of care episodes including assessments and medication reconciliation.
• Collaborates with PCP, family/caregiver, Social Worker, and Behavioral Health Specialists to evaluate needs and plan actions.
• Ensure timely documentation of clinical assessments and participate in in-person interdisciplinary care planning meetings.
• Lead in-person care planning meetings and provide nursing assessments and patient education for chronic conditions.
• Educate patients and families and advocate for their needs; document visits in the EHR.

Skills

RN license

CCM certification

Care coordination

Transitional nursing

Team collaboration

Patient education

Time management

Attention to detail

Education

Bachelor's degree in nursing

Job description

Oak Street Health in Indianapolis is hiring an RN Case Manager to lead care management for complex patients within a value-based care model. You will drive care coordination with the PCP, social worker, and care team to ensure continuity of care and reduce avoidable admissions.

This field-based role requires timely nursing assessments, medication reconciliation, transitions of care, and thorough documentation in the EHR.