Registered Nurse, Integrated Care Manager

Title: Registered Nurse, Integrated Care Manager

Location: Albuquerque, New Mexico

Reports to: 

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.

Role Description

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. 

Responsibilities

• 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

• Being scrappy

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.