Registered Nurse - Case Manager - Southeast Houston

Company Oak Street Health Title RN, Care Manager Location South Wayside 2008 S Wayside Dr #500, Houston, TX 77023 Fairmont 138b Fairmont Pkwy Suite 125, Pasadena, TX 77504 *Subject to adjustment based on clinic needs Role Description In partnership with the primary care provider (PCP), the RN, Care 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 standards. Other duties as assigned. Qualifications 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 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 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. Benefits Mission‑focused career impacting change and measurably improving health outcomes for Medicare patients. Paid vacation, sick time, and investment/retirement 401K 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. Additional Information Anticipated Weekly Hours: 40 Time Type: Full time Pay Range: $66,575.00 - $142,576.00 Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr