Lead Transitional Care Manager (RN)

Oak Street Health • Chicago, IL

378d

About The Position

The Lead Transitional Care Manager (RN) at Oak Street Health plays a crucial role in overseeing the Transitional Care Managers and executing the Transitions of Care program. This position focuses on providing high-quality, patient-centered care, preventing avoidable readmissions, and improving resource utilization and patient satisfaction. The TCM Lead collaborates with various stakeholders to ensure effective discharge planning and follow-up care, while also maintaining a portion of a patient panel.

Requirements

• Active RN or LCSW license within the state of practice in good standing.
• Cross-state licensure preferred, or willingness to obtain cross-state licensure.
• Nurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire.
• Minimum 2 years of direct supervisory experience.
• Minimum of 2 years of experience in transitional care nursing, discharge planning, or home health.
• Experience in utilization management.
• Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria.
• Strong clinical and assessment skills.
• Outstanding verbal and written communication skills.
• Ability to work independently and maintain flexibility in a fast-paced environment.
• Ability to analyze data and use it to improve care delivery.
• Self-starter with a high level of accountability and responsibility for the outcome of care.
• Highly organized and able to manage multiple priorities appropriately.
• Independent problem-solving skills.
• Ability to work collaboratively and build enduring relationships with providers, patients, and the multidisciplinary team.
• Access to reliable transportation with the ability to travel daily.

Nice To Haves

• Experience in a start-up environment.
• Familiarity with Microsoft Office Product Suite.

Responsibilities

• Supervise the Transitional Care Managers in assigned markets, including clinical oversight of daily operations and metrics.
• Evaluate patient status through clinical assessments and medical record review; manage inpatient and post-acute discharge planning.
• Reconcile medication lists on behalf of the primary care provider (PCP) and schedule post-discharge visits with the PCP.
• Partner with Utilization Management to review medical and payer records to ensure appropriate length of stay and address discharge barriers.
• Coordinate with internal stakeholders to promote patient outreach and engagement, identifying and addressing patient needs.
• Engage with external stakeholders to facilitate safe and timely discharge and appropriate follow-up care.
• Document and monitor transitions activities and effectiveness; participate in regular trainings and evaluate quality and impact of transitions activities.
• Balance staff caseloads and provide coverage and support as needed, maintaining up to 50% of a patient panel.
• Monitor team and individual performance, coaching team members to improve performance when appropriate.
• Assist with the hiring and training of Transitional Care Managers in assigned regions.
• Implement transitional care activities and programming, ensuring compliance with CMS, state, and NCQA criteria.
• Monitor OSH data related to patient cost, admissions, post-discharge appointment completion, and health outcomes.

Benefits

• Health insurance
• 401(k) matching
• Paid vacation and sick time
• Generous 401K match with immediate vesting

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: No Education Listed