Registered Nurse - Case Manager - Pontiac Michigan

Oak Street Health is committed to rebuilding healthcare by providing personalized primary care for older adults on Medicare. We focus on improving health outcomes and enabling patients to live life fully. Company: Oak Street Health Title: RN, Case Manager Location: Pontiac, 462 Telegraph Rd, Pontiac, MI 48341 Role Description In partnership with the primary care provider (PCP), the RN, Case Manager is the lead for care management activities. The role drives care coordination, collaborates with interdisciplinary teams, and ensures continuity of care for complex patients. Focus areas include preventing avoidable admissions, efficient resource utilization, and effective team-based care. This is a field‑based, on‑site role requiring strong relationships with patients, providers, and care team members. Core Responsibilities Manages 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. Owns overall care coordination for assigned patients, acting as the primary point of contact and ensuring alignment, accountability, and follow‑through across the care team. Manages transitions of care episodes, including timely completion of structured clinical assessments, medication reconciliation on behalf of the PCP, and addressing identified needs directly or with team members. Collaborates with the patient’s PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other care team members to evaluate needs, set goals, and develop action plans. Ensures timely documentation of key clinical assessments after admissions, balancing in‑center care team planning meetings. Leads in‑person interdisciplinary care planning meetings to coordinate and manage care between provider visits. Performs timely nursing assessments and provides patient education for chronic condition management and transitions of care. Educates patients and families, empowering them and advocating for their needs. Documents visits in the electronic health record according to internal standards. Other duties as assigned. Qualifications Current RN license in the assigned state is required; a bachelor's degree in nursing is preferred. Minimum of 6‑8 years of nursing experience. Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire, unless the candidate has 2‑3 years of relevant care/case management experience. 2+ years of 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 accessing community resources. Flexible and positive attitude. Comfort with ambiguity and change. High emotional intelligence, evidenced by the ability to evaluate situations from multiple perspectives and resolve problems. Access to reliable transportation and ability to travel throughout the communities Oak Street Health serves. US work authorization. Embodies Oak Street Health values. Benefits Mission‑focused career impacting measurable health outcomes for Medicare patients. Paid vacation, sick time, and 401(k) match options. Health, vision, and dental insurance. Leadership development and continuing education stipends. New centers and flexible work environments. Opportunities for high levels of responsibility and rapid advancement. Equal Opportunity Employer Oak Street Health is an equal‑opportunity employer. We embrace diversity and encourage all interested applicants to apply. Pay Range: $60,522.00 – $129,615.00 (annual) Anticipated Weekly Hours: 40 Time Type: Full time #J-18808-Ljbffr Hispanic Alliance for Career Enhancement