Nurse Practitioner Transitional Care
Nurse Practitioner Transitional Care
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$ 87035 - 187460
1 Vacancy
Job Description
At CVS Health were building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nations leading health solutions company we reach millions of Americans through our local presence digital channels and more than 300000 purposedriven 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.
Company:Oak Street Health
Title:Transitional Care Advanced Practice Provider (APP)
Location:Rockford IL
Salary: $115000 $148000
Role Description
The Advanced Practice Provider Transitions delivers hightouch highquality care to the highest risk patients attributed to Oak Street Health and the Oak Street Health RiskBearing Entity (RBE) within their homes. Our APPs lead a cohesive team of Oakies in delivering inhome support and care following adverse events which include inpatient admissions. APPs in a defined territory collaborate continuously with other team members for postdischarge follow up care coordination medication reconciliation and social services follow up. Provider teams enjoy easy access to clinical support from peers and medical directors and use best in class population health data to support patients when they need it most.
Core Responsibilities
Provide postdischarge support according to defined pathways within the patients home
Develop care plans and individualize goals of care with patient their families and their providers
Optimize and monitor clinical status identify and address gaps in care reconcile medications and address adherence challenges
Collaborate with Transitional Care Managers home health social workers hospitals SNFs and specialists
Structure and prioritize scheduling based on clinical complexity for both new and routine patients
Recognize diagnose and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
Provide afterhours and weekend call support shared with other in state providers
Facilitate and conduct goals of care and advance care planning discussions with patients and families
Assess and evaluate family / caregiver needs and limitations
Teach patients caregivers and others about their health conditions
Accurate and timely documentation of patient encounters in Oak Streets electronic medical record
Champion compliance and dissemination of policy including HIPAA Patient Identification and Incident Reporting
Other duties as assigned
What are we looking for
Genuine passion for reaching vulnerable patients
Strong clinical skills focused on older adults with complex disease states
Comfort navigating visits in patient homes
Demonstrated ability to collaborate effectively in a team setting
Willingness to learn and be accountable for visit documentation and workflows
Excellent communication followup teamwork and problemsolving skills
Desire to be a part of a fastpaced innovative qualitydriven organization
Required Qualifications
Have an active nonprobationary state medical license including US work authorization if applicable
1 years APN experience preferably with a Medicare population
Experience in homebased care (as RN or APP) preferred
Flexibility to travel throughout service area
Electronic Medical Record experience
Computer skills: Ability to quickly navigate and use multiple computer programs to include but not limited to: Gmail MS Word or Google Docs Excel or Google Sheets etc.
Additional language proficiency in Spanish Polish Russian or other languages spoken within the communities we serve preferred but not required
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 relentlessly determined
Why Oak Street Health
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 patients communities and focused on the quality of care over volume of services. Were 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 Benefits:
Missionfocused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation sick time and investment/retirement 401K match options
Health insurance vision and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.
Learn more at Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$87035.00 $187460.00This pay range represents the base hourly rate or base annual fulltime 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.
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.
Great benefits for great people
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:
Affordable medical plan options a 401(k) plan (including matching company contributions) and an employee stock purchase plan.
Nocost programs for all colleagues including wellness screenings tobacco cessation and weight management programs confidential counseling and financial coaching.
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.
For more information visit anticipate the application window for this opening will close on: 04/09/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal state and local laws.
Employment Type
Full-Time
