Registered Nurse Case Manager - East Texas

CVS Health • Tyler, TX

8d • Onsite

About The Position

Oak Street Health is hiring an RN Case Manager to lead care management activities in partnership with primary care providers. The role drives care coordination and collaborates with interdisciplinary teams to ensure continuity of care for complex patients, with an emphasis on preventing avoidable admissions, using resources efficiently, and delivering effective team-based care. This is a field-based, in-person position serving the Tyler and Longview, Texas clinics; clinic assignment may be adjusted based on needs.

The Case Manager manages an assigned caseload in a value-based care environment and is accountable for panel performance in admission prevention, readmission prevention, and transitions of care. The role serves as the primary point of contact for assigned patients and coordinates follow-through across the care team. It also manages transitions of care, conducts clinical assessments, reconciles medications on behalf of the PCP, provides nursing assessments and patient education, and documents care in the electronic health record.

The position partners with patients, families and caregivers, PCPs, social workers, behavioral health specialists, and other care team members to assess needs and goals, develop plans of action, and support care-plan progression. The RN leads in-person interdisciplinary care-planning meetings and advocates for patients’ needs. The role requires travel throughout the communities served and reliable transportation.

Requirements

• Current RN license in the assigned state.
• Minimum of 6–8 years of nursing experience.
• Certified Case Manager (CCM), or willingness to obtain certification within 12 months of hire, unless the candidate has 2–3 years of relevant care or case management experience.
• Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources.
• Flexible and positive attitude; comfort with ambiguity and change.
• High emotional intelligence, including the ability to consider multiple perspectives when resolving problems.
• Reliable transportation and ability to travel throughout the communities served.
• U.S. work authorization.
• Ability to embody Oak Street Health’s values: radiating positive energy, assuming good intentions, creating an unmatched patient experience, driving clinical excellence, taking ownership and delivering results, and being relentlessly determined.

Nice To Haves

• Bachelor’s degree in nursing preferred.
• Fluency in Spanish or other languages spoken by people in the communities served is strongly preferred.
• At least 2 years of experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health is strongly preferred.

Responsibilities

• Manage an assigned caseload of complex patients in a value-based care environment, focusing on reducing admissions, readmissions, and medical utilization.
• Meet panel metrics for admission prevention, readmission prevention, and transitions of care.
• Own care coordination for assigned patients as their primary point of contact, ensuring alignment, accountability, and follow-through across the care team.
• Manage transitions of care, including timely structured clinical assessments to identify post-discharge needs, medication reconciliation on behalf of the PCP, and addressing identified needs directly or with other team members.
• Collaborate with patients’ PCPs, families and caregivers, social workers, behavioral health specialists, and other care team members to evaluate needs and goals and advance care plans.
• Document key clinical assessments after admissions in a timely manner while balancing in-center care team planning meetings.
• Lead in-person interdisciplinary care-planning meetings to support coordination between provider visits.
• Perform timely nursing assessments and provide education on chronic condition management and transitions of care.
• Educate and empower patients and families and advocate for their needs.
• Document visits in the electronic health record according to internal standards.
• Perform other duties as assigned.
• Travel throughout the communities served by Oak Street Health.

Benefits

• Paid vacation and sick time.
• 401(k) match options and retirement savings options.
• Health insurance, including medical, dental, and vision coverage.
• Leadership development opportunities.
• Continuing education stipends.
• Wellness programs and other resources supporting physical, emotional, and financial well-being.
• Paid time off.
• Opportunities for high levels of responsibility and rapid advancement.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed