RN Case Manager - Field-Based Care Coordination

Oak Street Health, part of CVS Health; Allentown (Lehigh County); On-site; USD 61,000 - 130,000; Full time

Benefits offered by this job

Nutrition/Wellness stipends

Job summary

Oak Street Health, part of CVS Health, is seeking an RN Case Manager to lead care coordination for complex patients. In this field-based, on-site role, you will partner with PCPs and interdisciplinary teams to prevent avoidable admissions and optimize transitions of care.

You’ll manage your panel, document assessments in the electronic health record, and drive structured care plans in Bethlehem and Allentown clinics.

Qualifications

• Current RN license in assigned state is required; Bachelor degree in nursing preferred.
• Minimum of 6-8 years nursing experience.
• CCM certification required, or willingness to obtain within 12 months of hire, unless candidate has 2-3 years of relevant care/case management experience
• 2+ years experience in transitional nursing, ER nursing, care coordination, discharge planning, or home health is strongly preferred.
• Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources.
• A flexible and positive attitude
• Comfort with ambiguity and change
• High emotional intelligence as evidenced by ability to evaluate/perceive a situation from multiple lenses and understand various perspectives in coming to problem resolution.
• Access to reliable transportation and ability to travel throughout the communities OSH serves
• US work authorization
• Someone who embodies being Oaky

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 patient’s PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other care team members, as needed 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 providers 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.

Skills

Case management

Care coordination

Motivational interviewing

Time management

Patient education

Emotional intelligence

Travel readiness

Interdisciplinary collaboration

Community resources

Education

Bachelor's degree in nursing

Job description

Oak Street Health, part of CVS Health, is seeking an RN Case Manager to lead care coordination for complex patients. In this field-based, on-site role, you will partner with PCPs and interdisciplinary teams to prevent avoidable admissions and optimize transitions of care.

You’ll manage your panel, document assessments in the electronic health record, and drive structured care plans in Bethlehem and Allentown clinics.