RN Case Manager: Complex Care & Transitions Lead

CVS Health; Tyler (TX); On-site; USD 54,000 - 117,000; Full time

Benefits offered by this job

Vacation and sick time

401K match

Health, vision, and dental

Leadership development stipends

Flexible work environments

Career advancement

Job summary

Oak Street Health in Tyler, TX seeks an experienced RN, Case Manager to lead care coordination for complex patients on a value-based care team. This field-based role partners with PCPs, social workers, and other care team members to prevent unnecessary hospital admissions and ensure smooth transitions of care.

You will conduct timely nursing assessments, document in the EHR, and educate patients and families.

Qualifications

• Current RN license in assigned state required; CCM preferred or willingness to obtain within 12 months.
• 2+ years in transitional nursing, care coordination, discharge planning, or home health preferred.
• Fluency in Spanish or other languages spoken by the served communities preferred.
• Strong motivational interviewing and patient activation skills.
• Ability to travel throughout Oak Street Health communities.

Responsibilities

• Manage an assigned caseload of complex patients to reduce admissions and optimize resource use.
• Own panel metrics for admission prevention, readmission prevention and care transitions.
• Coordinate care across PCPs, family/caregivers, social workers and behavioral health specialists.
• Lead timely structured clinical assessments and medication reconciliation during transitions.
• Document visits in EHR and participate in in-person interdisciplinary care planning meetings.
• Educate and empower patients and families in self-management of chronic conditions.

Skills

Spanish language

Motivational interviewing

Time management

Care coordination

Discharge planning

Patient activation

Education

RN license in assigned state

Bachelor degree in nursing (preferred)

Certified Case Manager (CCM)

Tools

EHR software

Job description

Oak Street Health in Tyler, TX seeks an experienced RN, Case Manager to lead care coordination for complex patients on a value-based care team. This field-based role partners with PCPs, social workers, and other care team members to prevent unnecessary hospital admissions and ensure smooth transitions of care.

You will conduct timely nursing assessments, document in the EHR, and educate patients and families.