Senior RN Case Manager: Field-Based Care Coordination

CVS Health Corporation; Indianapolis (IN); On-site; USD 60,522 - 129,615; Full time

Benefits offered by this job

Paid vacation and sick time

Health, vision, and dental insurance

401K match options

Flexible work environments

Job summary

Oak Street Health is hiring an RN Case Manager in Indianapolis to lead care coordination for a complex patient panel within a value-based care model. The role emphasizes reducing unnecessary admissions, timely transitions of care, and coordinating with PCPs, families, and interdisciplinary teams.

Strong CCM certification and 6–8 years of nursing experience are required; a Bachelor’s in Nursing is preferred.

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, unless candidate has 2-3 years of relevant care/case management experience
• 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
• 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, focusing on reducing admissions, readmissions, and medical utilization.
• Accountable for panel metrics in admission and readmission prevention, and transitions of care.
• Owns overall care coordination for assigned patients and serves as primary contact across the care team.
• Manage transitions of care episodes with timely completion of structured clinical assessments and medication reconciliation.
• Collaborates with PCP, family/caregiver, Social Worker, Behavioral Health Specialists and others to evaluate needs and plan.
• Ensure timely documentation of key clinical assessments after admissions and participate in in-center planning meetings.
• Lead in-person interdisciplinary care planning meetings to coordinate care across providers.
• Perform nursing assessments and patient education for chronic condition management and transitions of care.
• Educate patients and families, empowering them in their care and advocating for needs.
• Document visits in the EHR according to internal standards.

Skills

Case management

Nursing experience

CCM certification

Care coordination

Discharge planning

Motivational interviewing

Education

Bachelor's degree in nursing

Job description

Oak Street Health is hiring an RN Case Manager in Indianapolis to lead care coordination for a complex patient panel within a value-based care model. The role emphasizes reducing unnecessary admissions, timely transitions of care, and coordinating with PCPs, families, and interdisciplinary teams.

Strong CCM certification and 6–8 years of nursing experience are required; a Bachelor’s in Nursing is preferred.