- Case Management
- Full-time
- Salary not listed
- Case Management
- Full-time
- $72,627 – $155,538
- License: New York
- 6+ years
Job description
Field-based RN Case Manager role with Oak Street Health in the Bronx/Flushing, NY. Partners with PCPs to lead care management for complex Medicare patients, focusing on preventing avoidable admissions and readmissions, managing transitions of care, and driving efficient resource utilization. Conducts in-person nursing assessments, medication reconciliation, and patient education. Leads interdisciplinary care planning meetings and serves as the primary point of contact for assigned patient panel. Requires Spanish fluency, active NY RN license, 6-8 years nursing experience, and CCM certification (or willingness to obtain within 12 months). Transitional nursing, ER, care coordination, or home health background strongly preferred.
Key responsibilities
- Manage caseload of complex Medicare patients in value-based care setting
- Lead transitions-of-care episodes including post-discharge assessments and med reconciliation
- Coordinate with PCP, social workers, and behavioral health team
- Lead in-person interdisciplinary care planning meetings
- Perform nursing assessments and chronic disease patient education
What you bring
- Active NY RN license
- Spanish fluency
- CCM certification
- Motivational interviewing
- Reliable transportation for community travel
Tags
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