Registered Nurse - Case Manager

RN, Case Manager

Location:

Hammond, IN 46320. Eligible candidates may receive a sign‑on bonus as part of the offer package.

• 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 addressing identified needs directly or via collaboration with other team members.
• Collaborate with 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.

• Fluency in Spanish or other languages spoken by people in the communities we serve (preferred).
• 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.
• 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.

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

• Pay range: $60,522.00 - $ (base rate).
• Eligible for CVS Health bonus, commission or short‑term incentive program in addition to the base pay range.
• Paid vacation, sick time, 401K match options.
• Health insurance, vision, and dental benefits.
• Opportunities for leadership development and continuing education stipends.
• New centers and flexible work environments.
• Opportunities for high levels of responsibility and rapid advancement.
• Anticipated weekly hours: 40.
• Time Type:
  Full time.