Nurse Practitioner, Transitional Care

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.

Company: Oak Street Health 

Title: Transitional Care Advanced Practice Provider (APP)

Location:  Indianapolis, IN

Role Description

The Advanced Practice Provider, Transitions delivers high-touch, high-quality care to the highest risk patients attributed to Oak Street Health and the Oak Street Health Risk-Bearing Entity (RBE) within their homes. Our APPs lead a cohesive team of Oakies in delivering in-home support and care following adverse events, which include inpatient admissions.  APPs in a defined territory collaborate continuously with other team members for post-discharge 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 post-discharge support according to defined pathways within the patient's 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 after-hours 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 Street's 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, follow-up, teamwork, and problem-solving skills

• Desire to be a part of a fast-paced, innovative, quality-driven organization

Required Qualifications

• Have an active, non-probationary state medical license, including US work authorization, if applicable

• 1+ years APN experience, preferably with a Medicare population

• Experience in home-based 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 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 Benefits: 

• Mission-focused 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

 

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$78,331.00 - $168,714.00

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.  
 

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.

• No-cost 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 https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 07/21/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.