RN Care Manager - Rutland

Community health

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties.

About the role

The Care Manager will collaborate with patients that have been identified through risk stratification. The care manager then supports the patient, their families and care team members to help a patient manage their medical conditions and co-occurring behavioral health, psychological and social determinants of health through the healthcare system. The Care Manager supports patients who are moving between health care practitioners, inpatient, and outpatient venues (including visiting nurses) and home settings as their condition and care needs change. It includes community resources and services that support a patient through one level of care to another.

Functions of the position

• Provide follow-up care to all identified patients based on level of complexity, social determinants of health and the identified stratification tool.
• Collaborate and coordinate care with any potential post discharge concern or barrier that has been identified.
• Provide transitional care to risk stratified patients post discharge from either outpatient or inpatient venues.
• Assure that hospital discharged patients have adequate education and knowledge of their medication list.
• Determine frequency of telephone encounters based on specific patient need.
• Identify barriers to care (includes social determinants of health) for care managed patients and will reach out to appropriate recourses based on patient needs.
• May determine at any time that a patient requires a face-to-face visit.

Skills required for success

• Current Vermont RN/LPN license.
• CPR Certification.
• Prior experience working in a nursing position required; prior case management experience in a similar outpatient setting preferred.