<p>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.</p> <p>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.</p> <p>Role Description:</p> <p>The Manager of Transitional Care is part of Oak Street Health's Transitional Care Leadership team and is responsible for overseeing Transitional Care Managers (TCM) and Leads across multiple states. OSH's Transitional Care program supports multidisciplinary care across facility-based care teams, OSH care teams, utilization management, care navigation, and patients and caregivers. The Manager provides leadership to TCM leads and directly to TCMs and is responsible for ensuring high-quality, patient-centered care, preventing avoidable readmissions, and maintaining high levels of provider, caregiver, and patient satisfaction.</p> <p>Responsibilities:</p> <ul> <li> <p>Supervise Lead TCMs and TCM-RNs / TCM-SWs in assigned markets, including clinical oversight of the following daily operations and metrics:</p> </li><li> <p>Transitions performance management: Provide guidance and oversight to TCM cohort, including evaluating team performance in the areas of: clinical assessments and medical record review, inpatient and post-acute discharge planning, reconciling medication lists (RN only) on behalf of the primary care provider (PCP), creating readmission prevention plans, and scheduling post-discharge visits with the PCP</p> </li><li> <p>Coordination with utilization management: partnering with UM to review medical and payer records and escalations to ensure appropriate length of stay and to identify and address any barriers to discharge.</p> </li><li> <p>Collaboration and communication with internal stakeholders: coordinating with internal stakeholders (e.g. care team, social work, behavioral health, utilization management, patient engagement, central telehealth, etc.) to promote patient outreach and engagement and identify and address patient needs.</p> </li><li> <p>Collaboration and communication with external stakeholders: Engaging directly with inpatient physicians, case managers, medical directors, social workers, hospitalists/SNFists (where applicable), and other care providers to facilitate safe and timely discharge and appropriate follow-up care; and identifying partnership development opportunities and systems improvements.</p> </li><li> <p>Documentation, tracking, reporting and training: Documenting and monitoring transitions activities and effectiveness; participating in regular trainings; evaluating quality and impact of transitions activities.</p> </li><li> <p>Manage daily operations, regional & facility assignments, caseloads, team and individual performance, and coaching, including indirect management via leads.</p> </li><li> <p>Hire and train Transitional Care Managers in assigned regions.</p> </li><li> <p>Assist with the implementation of transitional care activities and programming.</p> </li><li> <p>Execute effective collaboration between multi-disciplinary teams, including but not limited to: OSH Care Navigation, Utilization Management, facilities, local care teams, and patient/family.</p> </li><li> <p>Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.</p> </li><li> <p>Monitor OSH data related to patient cost, admissions, post-discharge appointment completion and health outcomes to help guide and direct Transitions of Care program initiatives and goals.</p> </li><li> <p>Other duties as assigned</p> </li></ul> <p>Ideal candidates have:</p> <ul> <li> <p>Bachelor's in Nursing or Master's in Social Work</p> </li><li> <p>Active RN or LCSW license within one or more OSH states</p> </li><li> <p>Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire</p> </li><li> <p>Willingness to obtain cross-state licensure, as needed</p> </li><li> <p>2+ years direct supervisory experience</p> </li><li> <p>4+ years in case management, transitional care, discharge planning, utilization management, and/or home health</p> </li><li> <p>Proficient with Microsoft Office, Google Suite, and healthcare EMRs</p> </li><li> <p>Knowledge of Medicare/Medicaid and NCQA requirements</p> </li><li> <p>Strong clinical and assessment skills</p> </li><li> <p>Outstanding verbal and written communication skills</p> </li><li> <p>Ability to work independently and maintain flexibility in a fast-paced, start-up environment</p> </li><li> <p>Self-starter with a high level of accountability and responsibility for the outcome of care</p> </li><li> <p>Highly organized and able to manage multiple priorities appropriately</p> </li><li> <p>Independent problem-solving skills</p> </li><li> <p>Able to work collaboratively and build enduring relationships with providers, patients and the multidisciplinary team.</p> </li><li> <p>A flexible, positive attitude</p> </li><li> <p>Valid driver's license and ability to travel daily</p> </li><li> <p>US work authorization</p> </li><li> <p>Someone who embodies being "Oaky"</p> </li></ul> <p>What does being "Oaky" look like?</p> <ul> <li> <p>Radiating positive energy</p> </li><li> <p>Assuming good intentions</p> </li><li> <p>Creating an unmatched patient experience</p> </li><li> <p>Driving clinical excellence</p> </li><li> <p>Taking ownership and delivering results</p> </li><li> <p>Being relentlessly determined</p> </li></ul> <p>Why Oak Street Health?</p> <p>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.</p> <p>Oak Street Health Benefits</p> <p>Mission-focused career impacting change and measurably improving health outcomes for Medicare patients</p> <ul> <li> <p>Paid vacation, sick time, and investment/retirement 401K match options</p> </li><li> <p>Health insurance, vision, and dental benefits</p> </li><li> <p>Opportunities for leadership development and continuing education stipends</p> </li><li> <p>New centers and flexible work environments</p> </li><li> <p>Opportunities for high levels of responsibility and rapid advancement</p> </li></ul> <p>Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.</p> <p>Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health</p> <p>Anticipated Weekly Hours</p> <p>40</p> <p>Time Type</p> <p>Full time</p> <p>Pay Range</p> <p>The typical pay range for this role is:</p> <p>$95,738.00 - $206,206.00</p> <p>This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p> <p>Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p> <p>Great benefits for great people</p> <p>We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:</p> <ul> <li> <p>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</p> </li><li> <p>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</p> </li><li> <p>Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</p> </li></ul> <p>For more information, visit https://jobs.cvshealth.com/us/en/benefits</p> <p>We anticipate the application window for this opening will close on: 07/28/2025</p> <p>Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p>