Registered Nurse - Case Manager - Bronx New York

RN, Case ManagerIn partnership with the primary care provider, 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.Core Responsibilities: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 with 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 standardsOther duties as assigned.What are we looking for?Fluency in Spanish or other languages spoken by people in the communities we serve, requiredCurrent 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 experience2+ 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 attitudeComfort with ambiguity and changeHigh 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 servesUS work authorizationSomeone who embodies being OakyWhat does being Oaky look like?Radiating positive energyAssuming good intentionsCreating an unmatched patient experienceDriving clinical excellenceTaking ownership and delivering resultsBeing relentlessly determinedWhy Oak Street Health?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 right in our patient communities, and focused on the quality of care over volume of services. We are an organization on the move! With over 200+ locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.Oak Street Health Benefits:Mission-focused career impacting change and measurably improving health outcomes for Medicare patientsPaid vacation, sick time, and investment/retirement 401K match optionsHealth insurance, vision, and dental benefitsOpportunities for leadership development and continuing education stipendsNew centers and flexible work environmentsOpportunities for high levels of responsibility and rapid advancementOak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.