Embedded Transitional Care Manager RN

• Manage patients through transitions of care
• Advocate for the patient throughout the care continuum
• Identify opportunities for improved program workflows
• Maintain real-time and accurate records of patient status
• Adhere to CMS, state specific and NCQA compliance criteria
• Evaluate patient status post-ED visit or observation stay
• Triage to determine appropriate follow up care
• Engage directly with inpatient physicians, case managers, medical directors, and hospitalists
• Coordinate with the Utilization Management team
• Conduct structured clinical assessment to identify post-discharge needs
• Conduct medication reconciliation on behalf of the PCP
• Collaborate with other transitions team members
• Communicate and coordinate with internal stakeholders
• Participate in regular meetings with Oak Street Health regional leaders
• Participate in regular meetings with the Program Director and other Transitional Care Managers
• Follow program procedures for documenting and tracking transitions interventions

• An active RN license within the state of practice in good standing
• Willingness to obtain cross-state licensure, as needed
• Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
• 2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
• Experience in utilization management preferred
• Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
• Exceptional communication skills and customer service orientation
• Innovative and independent problem solving skills
• Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
• Spanish-speaking preferred but not required
• A flexible, positive attitude
• Valid driver’s license and ability to travel daily
• Working knowledge of Microsoft Office Product Suite
• US work authorization

Spanish-speaking preferred but not required

• Paid vacation, sick time, and investment/retirement 401K match options
• Health insurance, vision, and dental benefits
• Affordable medical plan options
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access