Transitional Care Manager RN

Oak Street Health; Harrisburg (Dauphin County); Remote; USD 60,000 - 100,000; Full time

Job summary

An innovative healthcare provider is seeking a Transitional Care Manager RN to enhance patient care and manage transitions effectively. This role emphasizes high-quality, patient-centered care, focusing on preventing avoidable readmissions and ensuring resource management. You will collaborate with a dedicated team, engage with patients and caregivers, and work towards improving health outcomes for Medicare patients. Join a rapidly growing organization committed to transforming healthcare and making a meaningful impact in underserved communities. If you're passionate about patient care and embody a positive, determined spirit, this opportunity is for you.

Benefits

Paid Time Off

401(k) with match

Health Insurance

Vision Insurance

Dental Insurance

Wellness Programs

Counseling Services

Financial Coaching

Flexible Schedules

Family Leave

Qualifications

• 2+ years’ experience in transitional nursing, ER nursing, or home health.
• Willingness to obtain cross-state licensure if needed.

Responsibilities

• Manage patients through transitions of care, advocating for access to resources.
• Coordinate with internal and external stakeholders for safe discharges.

Skills

Transitional Nursing

ER Nursing

Discharge Planning

Utilization Management

Communication Skills

Problem-Solving Skills

Bilingual (Spanish)

Education

Active RN License

Certified Case Manager (CCM)

Tools

Microsoft Office Suite

Job description

Join to apply for the Transitional Care Manager RN role at Oak Street Health.

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels, and more than 300,000 purpose-driven colleagues—caring for people where, when, and how they choose in a way that is more connected, more convenient, and more compassionate. We do it all with heart, each and every day.

Company: Oak Street Health

Title: Transitional Care Manager, RN (CVS Healthspire)

Location: Remote

Oak Street Health is a rapidly growing, innovative company of community-based healthcare centers delivering higher quality health and wellness care that improves outcomes, manages medical costs, and provides an unmatched experience for adults on Medicare in underserved communities. By providing holistic, comprehensive, and integrated care in our patients’ communities, we help keep them healthy and reinvest cost savings into further care for these and other communities. Since 2013, Oak Street Health has brought its unique approach to tens of thousands of people nationwide. With ambitious growth plans, we seek team members who embody Oak Street values and are passionate about our mission to rebuild healthcare as it should be.

Role Description

Oak Street Health adopts a team-based approach to patient care. The Transitional Care Manager, RN (TCM-RN) is a key member of the team supporting patients managed by CVS Healthspire, Oak Street’s Managed Service Organization. The TCM-RN acts as the primary clinical care team member, facilitating interdisciplinary collaboration and ensuring care continuity across settings. The role involves empowering patients and caregivers to actively participate in post-ED/Observation and post-hospitalization care plans, providing information, addressing problems, and building relationships with care providers across various settings such as EDs, hospitals, SNFs, and outpatient facilities.

This role emphasizes high-quality, patient-centered care, preventing avoidable readmissions, and resource management.

Core Responsibilities

Transitions Management

• Manage patients through transitions of care, either face-to-face or telephonically, within a designated geographical area and care setting.
• Advocate for patient access to resources and resolve barriers to care.
• Identify opportunities for workflow improvements, partnerships, and quality enhancement.
• Maintain accurate, real-time records of patient status during care transitions.
• Adhere to CMS, state, and NCQA compliance standards related to Transitions of Care.

Transitions Management Responsibilities May Also Include:

• Evaluating patient status post-ED visit or observation stay, including assessments and record reviews.
• Triaging follow-up care, reviewing medications, and scheduling appointments.
• Engaging with inpatient physicians, case managers, and hospital staff to facilitate safe discharge and follow-up.
• Coordinating with Utilization Management to review records and ensure appropriate stays and discharge barriers.
• Informing patients and families about their condition, care plan, discharge instructions, and medication reconciliation.

Collaboration and Communication with Stakeholders

• Work with internal team members to ensure safe discharges and follow-up.
• Coordinate with primary care providers, social work, behavioral health, and utilization management teams.
• Participate in regular meetings to coordinate program implementation and management.

External Stakeholders

• Engage in meetings with program leaders and develop partnerships across the broader MSO model.

Documentation, Tracking, Reporting, and Training

• Complete training for transitions activities.
• Participate in quality assurance activities.
• Document and track interventions following program procedures.
• Ensure compliance with CMS, state, and NCQA standards.
• Perform other duties as assigned.

What are we looking for?

• Active RN license in good standing in the state of practice.
• Willingness to obtain cross-state licensure if needed.
• Certified Case Manager (CCM) or similar certification required or willing to obtain within 12 months.
• 2+ years’ experience in transitional nursing, ER nursing, discharge planning, or home health.
• Experience in utilization management preferred.
• Knowledge of Medicare/Medicaid and NCQA transitions of care criteria.
• Excellent communication and customer service skills.
• Problem-solving skills and ability to evaluate care options for quality and cost-effectiveness.
• Additional language skills (e.g., Spanish) are a plus.
• Flexible, positive attitude, valid driver’s license, and ability to travel daily.
• Proficiency with Microsoft Office Suite.
• US work authorization.
• Embodies “Oaky” values: positive energy, good intentions, patient focus, clinical excellence, ownership, and determination.

What does being “Oaky” look like?

• Radiating positive energy.
• Assuming good intentions.
• Creating an unmatched patient experience.
• Driving clinical excellence.
• Taking ownership and delivering results.
• Being relentlessly determined.

Why Oak Street Health?

Our mission is to rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, focusing on keeping patients healthy and living fully. Our care model is community-centered and quality-focused. With over 150 locations and rapid growth, we seek team members who share our values and passion.

Benefits

• Impactful career improving health outcomes for Medicare patients.
• Paid time off, 401(k) with match, health, vision, and dental insurance.
• Wellness programs, counseling, financial coaching, flexible schedules, family leave, and more.

Visit our benefits page for details. The application deadline is 11/05/2025. We are an equal opportunity employer committed to diversity and inclusion.