RN Case Manager: Value-Based Care with Sign-On Bonus

Oak Street Health

Indianapolis (IN)

On-site

USD 61,000 - 130,000

Full time

14 days+

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Benefits offered by this job

Sign-on bonus

Health insurance

Vision benefits

Dental benefits

401K match

Paid time off

Job summary

Oak Street Health in Indianapolis is seeking an experienced RN Case Manager to join our on-site care team. You will drive care coordination for complex patients, focusing on reducing avoidable admissions and ensuring effective transitions of care with the PCP and interdisciplinary teams.

The role requires aCurrent RN license and 6-8 years nursing experience, with CCM certification or plan to obtain within 12 months.

Qualifications

Current RN license in assigned state is required; Bachelor degree in nursing preferred.
Minimum of 6-8 years nursing experience.
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 and social resources.
A flexible and positive attitude; comfortable with ambiguity and change.

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 across the care team.
Manage transitions of care episodes for patients on their panel, including structured clinical assessments and medication reconciliation on behalf of the PCP.
Collaborates with patient’s PCP, family/c caregiver, Social Worker, Behavioral Health Specialists, and other care team members to evaluate needs, goals, and plan of action.
Ensure timely documentation of key clinical assessments after admissions and participate in in-center care team planning meetings.
Lead in-person interdisciplinary care planning meetings to ensure effective care coordination.
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 the EHR according to internal standards.