Registered Nurse, Integrated Care Manager
Title: Registered Nurse, Integrated Care Manager
Location: Albuquerque, NM
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.
For more information, visit www.oakstreethealth.com.
Oak Street Health takes a team-based approach to providing outstanding patient care. As a part of the care management team, you would be providing care to an underserved area of the community. The OSH Team is responsible for delivering excellent, high-touch, primary care, and coordinating the care of our patients throughout the healthcare delivery system. Registered Nurses (RNs) are an important part of Oak Street Health’s success. High levels of flexibility, attention to detail, and problem solving are required to be successful. You will be expected to carry a caseload, build relationships with Oak Street Health patients, manage patient’s care plans, perform proactive phone and in-person outreach to our patients based on their care needs, complete assessments, support Care Team decision making, participate in weekly care team meetings, and generally coordinate all clinical and auxiliary services needed to provide a high quality health care experience from Oak Street Health.
Direct patient care to Oak Street patients within the center by providing support and triage for needs, scheduling problem visits or nurse visits when appropriate, offering symptom management, supporting refill requests and answering visit follow-up questions
Provide patient education, particularly around chronic conditions; may occur in person, over the phone or in groups (as needed)
Monitor and coordinate delivery of the care plan, including routine follow up to ensure the progression and completion of all activities and interventions outlined in the members care plan
Provide direction to MAs to support delivery of procedures, telephonic support and patient instructions, as needed
Conduct medication and testing authorization, as needed
Deliver an exceptional patient experience through service, responsiveness and care
Manage an assigned caseload while remaining in compliance with all internal and regulatory requirements
Collaborates with internal care teams as well as external healthcare professionals, patient social supports and insurance resources to assess the patient’s healthcare needs and ensure successful outcome of care plan goals, including the scheduling, leading and maintenance of interdisciplinary care team (ICT) meetings
Conduct assessment(s) to identify individual patient needs and goals, develops a specific patient-centered care plan to address problems, set goals and interventions as identified during the assessment
Assess patients’ psychosocial needs and promotes access to community resources
Form relationships with patients and their caregivers to support prevention focused care and ED/ hospital diversion, where appropriate and focusing interventions on reduction of avoidable hospital admissions, readmissions and ED visits
Maintain HIPAA standards and confidentiality of protected health information
Capacity to transport oneself to members’ homes and facilities and comply with travel and mileage reimbursement policies
Assist with the completion of applications to access eligible benefits
Partner with Care Team throughout inpatient and post acute episodes of care
Maintain clear documentation of patient enrollment and progression through programs within compliance timeframes
Practice in accordance with applicable laws and standards, and ethical principles
Performs other job duties as requested by leadership team, including the participation in compliance audits
What are we looking for?
Current state license to practice as a Registered Nurse
CPR Certification required
Minimum of 2 years of relevant healthcare experience preferred
Bilingual in Spanish or other languages spoken by people in the communities we serve is preferred
Experience with motivational interviewing, behavior change, health promotion, and coaching
Knowledge of payer managed care programs preferred
Strong communication skills and customer service orientation
Accomplished problem-solving skills and a highly flexible and accountable work ethic
Experience working with multiple software platforms, electronic health records, google suite, including gmail and google documents, Microsoft Office product suite, spreadsheet development and navigation, data processing
A positive and supportive attitude toward our patient population with the ability to exhibit Oak Street Health’s values in daily interactions
Ability to work autonomously, follow through with delegated tasks, and be directly accountable for deliverables in a faced-paced environment
Outstanding verbal and written communication skills
A high-level of accountability and responsibility for the outcome of care
Excellent interpersonal and facilitation skills
Excellent organizational skills and ability to manage multiple priorities appropriately
Independent problem-solving skills
Experience working with Suburban and Rural neighborhood members
Ability to demonstrate cultural sensitivity, effective communication, and motivational interviewing skills
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
Why Oak Street?
Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as:
Collaborative and energetic culture
Fast-paced and innovative environment
Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.