Registered Nurse Case Manager - Indianapolis - Sign On Bonus

Company Oak Street Health Title RN, Case Manager Location University Heights, 4200 S. East St, Indianapolis, IN 46227 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 field‑based, in‑person/on‑site role focuses on preventing avoidable admissions, driving efficient resource utilization, and ensuring effective team‑based care. 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, functioning 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 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 the individual's needs, goals, and plan of action and ensure care plan progression. Ensures timely documentation of key clinical assessments after admissions, 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 advocating for their needs. Documents visits in electronic health record according to internal standards. Other duties as assigned. What are we looking for? Current RN license in the 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 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 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. Oak Street Health Benefits Mission‑focused career impacting change and measurably improving health outcomes for Medicare patients. Paid vacation, sick time, and 401(k) match options. Health, 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. Anticipated Weekly Hours 40 Time Type Full time Pay Range $60,522.00 - $129,615.00 This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above. Equal Opportunity Statement Oak Street Health is an equal opportunity employer. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr