- Specialty
- Case Management
- Type
- Contract
Job description
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, Case Manager Location: Simpson 1024 Westchester Ave, Bronx, NY 10459 Jackson Heights 97-01 Northern Blvd, Flushing, NY 11368
- Subject to adjustment based on clinic needs
- 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 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, required
- 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
- US 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
- Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
- Paid vacation, sick time, and investment/retirement 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