Transitional Care Manager RN — Compact license required

Oak Street Health is on a mission to ​“Rebuild healthcare as it should be,” providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient’s communities, and focused on the quality of care over volume of services. We’re an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody ​“Oaky” values and passion for our mission.

Oak Street Health takes a team-based approach to providing outstanding patient care. 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 TCM-RN’s role is to provide information and support for the patient in identifying and addressing problems and building relationships with providers and care teams in various sites of care (e.g., ED, hospital, SNF, Oak Street Health clinics). This role prioritizes the relationship with the patient/​family; providing high-quality, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization.

Transitions Management: Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting. Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care. Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care. Maintain real-time and accurate records of patient status through care transitions within Oak Street’s internal inpatient platform. Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care. Depending on the clinical scope of the transitions program in specific regions, transitions management responsibilities may also include: Emergency Department and Observation Stays Evaluate patient status post-ED visit or observation stay through a clinical assessment and medical record review. 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. Hospital Inpatient Stays 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. Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge. Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations. 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. Post-Discharge from an Inpatient or Post-Acute Stay 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. Conduct medication reconciliation on behalf of the PCP. Address identified post-discharge needs directly or via collaboration with other team members . Collaboration and Communication with Internal Stakeholders 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. 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.). Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management. Collaboration and Communication with External Stakeholders Participate in regular meetings with the Program Director and other Transitional Care Managers on programmatic development and clinical learning. Identify partnership development opportunities and systems improvements. Coordinate with Regional Leaders and hospital partners to implement system improvements. Documentation, Tracking, Reporting and Training Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming. Participate with the TCM Lead in quality assurance activities. Follow program procedures for documenting and tracking transitions interventions. Adhere to CMS, state, and NCQA compliance criteria as related to Transitions of Care. Other duties, as assigned.