Embedded Transitional Care Manager -RN Location Philadelphia

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.

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

• 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 appli