RN Case Manager: Care Coordination for Complex Patients

CVS Health; Arkansas; On-site; USD 61,000 - 130,000; Full time

Benefits offered by this job

Health insurance

Vision and dental benefits

Paid vacation and sick time

401K match options

Leadership development & continuing ed

Job summary

Oak Street Health is hiring a Registered Nurse, Case Manager to lead care coordination for a panel of complex patients in a value-based care setting. This field-based role emphasizes reducing admissions, readmissions and optimizing transitions of care.

You will partner with PCPs, social workers, and care team members to assess needs, coordinate post-discharge care and ensure timely documentation in the EHR. Requires CCM or willingness to obtain; traveling within communities served is expected.

Qualifications

• Current RN license in assigned state is required.
• Bachelor degree in nursing preferred.
• Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire.
• 2+ years experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health is strongly preferred.
• Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community resources.
• Access to reliable transportation and ability to travel throughout the communities OSH serves.

Responsibilities

• Manages an assigned caseload of complex patients in a value-based care environment, with a focus on driving reduced admissions, readmissions, and medical utilization.
• Accountable for panel metric performance in admission prevention, readmission prevention, and transitions of care metrics.
• Owns 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 addressal of identified needs directly or via collaboration with other team members.
• Collaborates with patient’s PCP, family caregiver, Social Worker, Behavioral Health Specialists, and other care team members to evaluate needs, goals and plan of action.

Job description

Oak Street Health is hiring a Registered Nurse, Case Manager to lead care coordination for a panel of complex patients in a value-based care setting. This field-based role emphasizes reducing admissions, readmissions and optimizing transitions of care.

You will partner with PCPs, social workers, and care team members to assess needs, coordinate post-discharge care and ensure timely documentation in the EHR. Requires CCM or willingness to obtain; traveling within communities served is expected.