RN,CaseManager

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. ****Company:**** Oak Street Health ****Title:** **RN, Case Manager ****Location:**** **Jefferson Village** 11260 E Jefferson Ave, Detroit, MI 48214 ****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 Hea