Registered Nurse - Case Manager - Southwest 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.

Company: Oak Street Health

Title: RN, Case Manager

Location: 6806 S Texas 6 A, Houston, TX 77083 – West Belfort Clinic

* Subject to adjustment based on clinic needs

In partnership with the primary care provider (PCP), the RN, Case Manager is the lead for 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 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 addressing identified needs directly or via collaboration with other team members.
• Collaborates with patient’s PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other care team members 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 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 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 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 to evaluate situations from multiple perspectives and resolve issues
• Access to reliable transportation and ability to travel throughout the communities OSH serves
• US work authorization
• Someone who embodies being Oaky

• 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 care model centers in patient communities and focuses on…