Role Description:

The RN, Complex Care Manager leads complex care management, delivers nursing interventions, and collaborates with interdisciplinary teams to ensure care continuity for complex patients. This role focuses on patient/family relationships, high-quality patient-centered care, preventing avoidable admissions, and efficient resource utilization. It is a primarily field-based, in-home care reporting to the Sr. Mgr, Nursing Strategy.

Core Responsibilities:

• Manage an assigned caseload of complex patients towards their optimal overall health and well-being, with a focus on management of chronic conditions, addressing social needs, and driving coordination of care.
• Develop and maintain a person-centered, individualized care plan all patients in assigned caseload, involving the 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
• Act as a central point of contact for patient in care coordinate, facilitate communication and collaboration between the PCP and care team
• Deliver nursing interventions for chronic condition management and transitions of care.
• Complete all activities and interventions outlined in the members care plan and ongoing monitoring of cases to ensure routine follow up and progression in their care plan goals; conduct timely, specific, and comprehensive programmatic assessments
• Educate patients and families, empowering them in their care, and advocating for their needs.
• Attend and participate in in-person interdisciplinary care team meetings to ensure effective care coordination and management
• Conduct home visits; identify and facilitate referrals to community resources, monitoring resource utilization.
• Document visits in electronic health record according to internal standards
• Other duties as assigned.

What are we looking for?

• Bachelor's degree in nursing required; advanced degree preferred.
• Current RN license in assigned state.
• Ability to communicate effectively in Spanish preferred.
• US Work Authorization.
• Minimum of 6-8 years nursing experience
• CM certification required OR 2-3 years of care / case management experience
• Demonstrated skill in problem solving, critical thinking, conflict resolution, and exceptional communication skills.
• A flexible and positive attitude, and a strong desire to change the traditional primary care paradigm.
• 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

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, 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 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

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.

Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health