Embedded Transitional Care Manager- RN

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Company: Oak Street Health

Title: Embedded Transitional Care Manager - RN (Hospital-based)

Location: PA

Oak Street Health is a rapidly growing, innovative company of community-based healthcare centers delivering higher quality health and wellness care that improves outcomes, manages medical costs and provides an unmatched experience for adults on Medicare in medically underserved communities. By providing holistic, comprehensive and integrated care right in our patients' communities, we can help keep them healthy and reinvest cost savings in further care for those same communities and others. Since 2013, Oak Street Health has brought its singular approach to tens of thousands of people across the nation. With an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oak Street values and are passionate about our mission to rebuild healthcare as it should be.

Role Description:

Oak Street Health takes a team-based approach to providing outstanding patient care. Embedded Transitional Care Manager - RN (TCM-RN) is an integral part of the team. The TCM-RN is the primary member of the Oak Street clinical care team and facilitator of interdisciplinary collaboration and care continuity across care settings and systems, empowering the patient and/or caregiver to play an active and informed role in post-ED/Observation and post-hospitalization care plan execution. The embedded TCM-RN's role is to provide on-site/bedside discharge planning support to patients, including identifying and addressing problems and building relationships with providers and care teams across various sites of care (e.g. ED, hospital, SNF, primary care clinics).

This role prioritizes the relationship with the patient/family and inpatient facility; providing high-quality, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization.

Core Responsibilities:

Transitions Management

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  Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting.
  
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  Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care.
  
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  Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care.
  
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  Maintain real-time and accurate records of patient status through care transitions within Oak Street's internal inpatient platform.
  
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  Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.
  
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  Depending on the clinical scope of the transitions program in specific regions, transitions management responsibilities may also include:
  
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    Emergency Department and Observation Stays
    
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      Evaluate patient status post-ED visit or observation stay through a clinical assessment and medical record review.
      
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      Triage to determine appropriate follow up care and next steps, including reviewing medication lists and scheduling follow up appointments with the appropriate provider and/or specialists.
      
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    Hospital Inpatient Stays
    
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      Engage directly with inpatient physicians, case managers, medical directors, and hospitalists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps.
      
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      Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge.
      
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      Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations.
      
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      Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, all discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow-up following discharge.
      
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    Post-Discharge from an Inpatient or Post-Acute Stay
    
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      Conduct structured clinical assessment to identify post-discharge needs, including but not limited to: medications, specialist appointments, home health, DME, caregiver support, social determinants of health, etc.
      
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      Conduct medication reconciliation on behalf of the PCP
      
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      Address identified post-discharge needs directly or via collaboration with other team members
      

Collaboration and Communication with Internal Stakeholders

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  Collaborate with other transitions team members (e.g. Transitional Care Managers - Social Work and Transitional Care Coordinators) to ensure safe discharge and timely follow up.
  
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  Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g. care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.).
  
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  Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management.
  

Collaboration and Communication with External Stakeholders

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  Participate in regular meetings with the Program Director and other Transitional Care Managers on programmatic development and clinical learning.
  
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  Identify partnership development opportunities and systems improvements. Coordinate with Regional Leaders and hospital partners to implement system improvements.
  

Documentation, Tracking, Reporting and Training

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  Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming.
  
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  Participate with the TCM Lead in quality assurance activities.
  
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  Follow program procedures for documenting and tracking transitions interventions.
  
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  Adhere to CMS, state, and NCQA compliance criteria as related to Transitions of Care.
  
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  Other duties, as assigned.
  

What are we looking for?

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

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$66,575.00 - $142,576.00

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 our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

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  Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
  
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  No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
  
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  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 and many other benefits depending on eligibility.
  

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 06/13/2025

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