Registered Nurse - Case Manager - East Texas

Company

Oak Street Health

RN, Case Manager

• 2115 S Broadway Ave, Tyler, TX 75701
• 1207 E Marshall Ave, Longview, TX 75601

In partnership with the primary care provider (PCP), the RN, Case Manager is the lead for care management activities. The role drives care coordination and collaborates with interdisciplinary teams to ensure continuity of care for complex patients. The focus is on preventing avoidable admissions, driving efficient resource utilization, and ensuring effective team‑based care. This field‑based, in‑person/on‑site role requires strong relationships between patients, providers and care team members.

• Manages an assigned caseload of complex patients in a value‑based care environment, focusing on 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.
• Manages transitions of care episodes for patients on the 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.
• Collaborates with patient’s PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other care team members to evaluate the individual’s needs, goals, and plan of action and ensure care plan progression.
• Ensures timely documentation of key clinical assessments after admissions while balancing in‑center care team planning meetings.
• Leads in‑person interdisciplinary care planning meetings to ensure effective coordination and management between provider visits.
• Performs timely nursing assessments and provides patient education for chronic condition management and transitions of care.
• Educates patients and families, empowers them in their care, and advocates for their needs.
• Documents 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 served (strongly preferred).
• Current RN license in the assigned state (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; candidates with 2–3 years of relevant care/case management experience may qualify without CCM.
• 2+ years experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health (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 evidenced by the ability to evaluate/perceive a situation from multiple lenses and to understand various perspectives in problem resolution.
• Access to reliable transportation and ability to travel throughout the communities served by OSH.
• U.S. work authorization.
• Someone who embodies being Oaky.

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

Anticipated Weekly

Hours:

40

Time Type:
Full time

Pay Range: $54,095.00 - $ (base). The actual base salary offer will depend on experience, education, geography, and other relevant factors. The position is eligible for a CVS Health bonus, commission or short‑term incentive program.

• Paid vacation, sick time, and retirement 401(k) match options.
• Health, vision and dental benefits.
• Leadership development and continuing education stipends.
• New centers and flexible work environments.
• Opportunities for high levels of responsibility and rapid advancement.

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.