Registered Nurse Case Manager

Job Title and Location

RN, Case Manager – University Heights, Indianapolis, IN 46227

In partnership with the primary care provider (PCP), the RN, Care Manager leads care management activities, drives care coordination, and collaborates with interdisciplinary teams to ensure care continuity for complex patients. This field‑based, in‑person role focuses on preventing avoidable admissions, driving efficient resource utilization, and ensuring effective team‑based care.

• 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.
• Manages 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 with the 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.
• 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 care coordination and management between providers visits.
• Performs timely nursing assessments and provides patient education for chronic condition management and transitions of care.
• Educates patients and families, empowering them in their care, and advocating for their needs.
• Documents visits in electronic health record according to internal standards.
• Other duties as assigned.

• 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 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.
• Access to reliable transportation and ability to travel throughout the communities served.
• US work authorization.

Pay Range: $60,522.00 – $ (annual)

Anticipated Weekly

Hours:

40

• Mission‑focused career impacting change and measurably improving health outcomes for Medicare patients.
• Paid vacation, sick time, and investment/retirement 401(k) 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.

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.