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 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. What are we looking for? 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. 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 401 K 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 Anticipated Weekly Hours 40 Time Type. Full time. Pay Range. The typical pay range for this role is:$60,522.00 - $129,615.00