Registered Nurse - Case Manager - Southwest Dallas

Company Oak Street Health Title RN, Case Manager Locations Duncanville Clinic, 319 S Cedar Ridge Dr, Duncanville, TX 75116 North Arlington Clinic, 819 E Abram St, Arlington, TX 76010 Role Description 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 continuity of care for complex patients. The 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 that requires strong relationships between patients, providers, and care team members. Core Responsibilities Manages an assigned caseload of complex patients in a value‑based care environment, focusing on 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, serving as the primary point of contact and ensuring alignment, accountability, and follow‑through across the care team. Manages 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 direct or collaborative resolution of identified needs. Collaborates with the patient’s PCP, family/caregiver, social worker, behavioral health specialists, and other care team members to evaluate individual needs, goals, and plan of action and ensure care plan progression. Ensures timely documentation of key clinical assessments after admissions while balancing in‑center care team planning meetings. Leads in‑person interdisciplinary care planning meetings to ensure effective care coordination and management 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 in their care, and advocates for their needs. Documents visits in the electronic health record according to internal standards. Other duties as assigned. What Are We Looking For? 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’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 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 as evidenced by ability to evaluate and perceive situations from multiple viewpoints and understand various perspectives in problem resolution. Access to reliable transportation and ability to travel throughout the communities OSH serves. US work authorization. Someone who embodies being Oaky. What Does Being Oaky Look Like? Radiating positive energy. Assuming good intentions. Creating an unmatched patient experience. Driving clinical excellence. Taking ownership and delivering results. Being relentlessly determined. Why 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, attracting and cultivating team members who embody Oaky values and passion for our mission. Benefits Mission‑focused career impacting change and measurably improving health outcomes for Medicare patients. Paid vacation, sick time, and investment/retirement 401(k) 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. Pay Range $60,522.00 - $129,615.00 Time Type Full time Anticipated Weekly Hours 40 Application Window Our application window will close on 04/30/2026. EEO Statement Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. Qualified Applicants Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws. For more information, visit #J-18808-Ljbffr Signify Health