Registered Nurse - Case Manager - Northwest Houston

Overview

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.

Title: RN, Case Manager

Company: Oak Street Health

Location: Cypress Clinic, 11600 FM 1960 Rd W Houston, TX 77065;
White Oak Clinic, 5760 W Little York Rd Houston, TX 77091

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 care continuity for complex patients. This 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.

• Manages an assigned caseload of complex patients in a value-based care environment, with a focus on reducing 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, serving 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 addressing 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 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 the 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 (strongly preferred).
• Current RN license in the assigned state;
  Bachelor’s 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.
• A flexible and positive attitude; comfortable with ambiguity and change.
• High emotional intelligence with ability to evaluate situations from multiple perspectives and resolve problems.
• 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

Oak Street Health is on a mission to rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare. Our care model focuses on quality of care over volume,…