RN, Care Manager; PA

Company

Oak Street Health

RN, Care Manager

Reading Clinic: 951 N 6th St. Suite 221 Reading, PA 19601

Lancaster Clinic: 790 New Holland Ave Suite B Lancaster, PA 17602

York Clinic: 1113 Carlisle Rd York, PA 17404

Subject to adjustment based on clinic needs.

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 continuity for complex patients. This field‑based, in‑person/on‑site role focuses on preventing avoidable admissions, driving efficient resource utilization, and ensuring effective team‑based care.

• Manage an assigned caseload of complex patients in a value‑based care environment, focusing on reducing 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 the primary point of contact and ensuring alignment and accountability across the care team.
• Manage transitions of care episodes for panel patients, including timely completion of structured clinical assessments, medication reconciliation on behalf of the PCP, and addressing identified needs directly or via collaboration.
• Collaborate with patients’ PCP, family/caregiver, social worker, behavioral health specialists, and other team members to evaluate needs, goals, and 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 coordinate care 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 and advocating for their needs.
• Document visits in electronic health record according to internal standards.
• Other duties as assigned.

• Current RN license in assigned state; bachelor’s degree in nursing preferred.
• Minimum 6‑8 years of nursing experience.
• Certified Case Manager (CCM) required, or willingness to obtain within 12 months, unless 2‑3 years of relevant care/case management experience.
• 2+ years of experience in transitional nursing, emergency department, care coordination, discharge planning, or home health strongly preferred.
• Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community resources.
• Flexible and positive attitude.
• Comfort with ambiguity and change.
• High emotional intelligence evidenced by ability to evaluate multiple perspectives and resolve problems.
• Access to reliable transportation and ability to travel throughout the communities OSH serves.
• 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.

Oak Street Health is on a mission to rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered in patient communities, focusing on quality of care over volume of services. With over 200+ locations and an ambitious growth trajectory, we attract team members who embody Oaky values and passion for our mission.

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

Typical pay range: $66,575.00 – $. This represents the base hourly rate or base annual full‑time salary for all positions in the job grade.…