RN Case Manager: Care Coordinator & Transitions Lead

8350 Oak Street Health MSO LLC; Irvington (KY); On-site; USD 61,000 - 130,000; Full time

Benefits offered by this job

Sign-on bonus

Health insurance

Dental benefits

401K match

Job summary

Oak Street Health is seeking an RN, Case Manager in Indianapolis area to lead care coordination with PCPs for complex patients. This field-based, on-site role emphasizes preventing avoidable admissions and efficient resource use.

Requirements include an active RN license, 6–8 years of nursing experience, and CCM certification or plan to obtain within 12 months. Travel across Oak Street Health communities is expected.

Qualifications

• Current RN licence in assigned state is required; Bachelor degree in nursing preferred.
• 6–8 years nursing experience.
• Certified Case Manager (CCM) required, or willing to obtain within 12 months.
• 2+ years experience in transitional nursing, care coordination, discharge planning or home health.
• Strong motivational interviewing and patient activation skills.
• Must have reliable transportation and be able to travel throughout OSH communities.

Responsibilities

• Lead care management activities with PCP collaboration to ensure care continuity.
• Manage an assigned caseload of complex patients to reduce admissions and readmissions.
• Own panel metrics for admission prevention, readmission, and transitions of care.
• Coordinate care transitions and ensure timely assessments and medication reconciliation.
• Lead in-person interdisciplinary care planning meetings with the care team.
• Document visits in the EHR per internal standards.
• Educate patients and families and advocate for their needs.
• Collaborate with Social Workers, Behavioral Health Specialists and others as needed.

Skills

RN license

CCM certification

Care coordination

Motivational interviewing

Time management

Interdisciplinary collaboration

Travel to OSH communities

Education

Bachelor degree in nursing

Tools

EHR (Electronic Health Records)

Job description

Oak Street Health is seeking an RN, Case Manager in Indianapolis area to lead care coordination with PCPs for complex patients. This field-based, on-site role emphasizes preventing avoidable admissions and efficient resource use.

Requirements include an active RN license, 6–8 years of nursing experience, and CCM certification or plan to obtain within 12 months. Travel across Oak Street Health communities is expected.