Registered Nurse - Case Manager

RN, Case Manager

Location:

Belmont Ave 3551 Belmont Ave Suite 19-B, Youngstown, OH 44505.

In partnership with the primary care provider (PCP), the RN, Case Manager leads care management activities, drives care coordination, and collaborates with interdisciplinary teams to ensure continuity of care for complex patients. The 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.

• Manage 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.
• Own overall care coordination for assigned patients, serving as primary point of contact and ensuring alignment, accountability, and follow‑through across the care team.
• Manage transitions of care episodes, 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 patients’ 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 coordination and management between provider 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 the electronic health record according to internal standards.
• Perform 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 is strongly preferred.
• Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources.
• Flexible and positive attitude with comfort with ambiguity and change.
• High emotional intelligence, evidenced by ability to evaluate / perceive a situation from multiple lenses and understand various perspectives for problem resolution.
• Access to reliable transportation and ability to travel throughout the communities served.
• US work authorization.

• Mission‑focused career impacting change and measurably improving health outcomes for Medicare patients.
• Paid vacation, sick time, and 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.

Anticipated weekly hours: 40. Full‑time. Pay range: $60,522.00 – $, with actual offer depending on experience, education, geography and other factors. Position eligible for CVS Health bonus, commission or short‑term incentive program in addition to the base pay range.