Registered Nurse - Case Manager - Northwest Houston

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
**** Company:
** Oak Street Health
*****
* Title:

** RN, Care Manager
*****
* Location:

****** Cypress Clinic
**** 11600 FM 1960 Rd W Houston, TX 77065
**** White Oak Clinic
**** 5760 W Little York Rd Houston, TX 77091
**** Subject to adjustment based on clinic needs
****** Role

Description:

**** In partnership with the primary care provider, (PCP), the RN, Care Manager is the lead for care management activities, drives care coordination and collaborates with interdisciplinary teams to ensure care continuity for complex patients. This role focuses on preventing avoidable admissions, driving efficient resource utilization, and ensuring effective team-based care. It is a field-based, in-person/on-site role, requiring strong relationships between patients, providers and care team members.
***
* Core 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.
* Fluency in Spanish or other languages spoken by people in the communities we serve, strongly 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.
* 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
* Fluency in Spanish or other languages spoken by people in the communities we serve, strongly preferred
* US work authorization
* Someone who embodies being Oaky
* Radiating positive energy
* Assuming good intentions
* Creating an unmatched patient experience
* Driving clinical excellence
* Taking…