Transitional Case Manager Jobs in Cleveland, OH (NOW HIRING)

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Company: Oak Street Health 

Title: RN, Case Manager 

Location:

Lee Harvard

16888 Harvard Ave, Cleveland, OH 44128 ​

Glenville

10553 St Clair Ave., Cleveland, OH 44108

*Subject to adjustment based on clinic needs

Role Description:
In partnership with the primary care provider, (PCP), the RN, Case Manager is the lead for care management activities, drives care coordination and collaborates with interdisciplinary teams to ensure care continuity for complex patients. This role focuses on preventing avoidable admissions, driving efficient resource utilization, and ensuring effective team-based care. It is a field-based, in-person/on-site role, requiring strong relationships between patients, providers and care team members.

Core Responsibilities:

• 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 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

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.