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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 the Care Manager will collaborate with patients identified through risk stratification, focusing on emergency room and inpatient discharge follow-ups, inpatient readmissions, transitions of care, and geriatric patient health needs.
- The Care Manager supports patients, their families, and care team members to manage medical conditions and co-occurring behavioral health, psychological, and social determinants of health through the healthcare system.
- The Care Manager supports patients transitioning between healthcare practitioners, inpatient, and outpatient venues (including visiting nurses) and home settings as their condition and care needs change.
- This 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 their level of complexity, social determinants of health, and the identified stratification tool.
- Collaborate and coordinate care with any potential post-discharge concerns or barriers that have been identified.
- Provide transitional care to risk-stratified patients post-discharge from either outpatient or inpatient venues.
- Ensure that hospital-discharged patients have adequate education and knowledge of their medication list.
- Determine the frequency of telephone encounters based on specific patient needs.
- Identify barriers to care (including social determinants of health) for care-managed patients and reach out to appropriate resources based on patient needs.
- Determine at any time that a patient requires a face-to-face visit.
- Utilize an identified schedule to follow up with their patients.
- Follow up with all identified care-managed hospital discharge patients who do not keep their appointments and provide additional follow-up based on patient needs.
- Make referrals to the Care Manager whenever a primary nurse or provider identifies a complex or high-risk patient, irrespective of whether the patient has been hospitalized.
- Review patient lists to identify patients requiring care management services.
- Work with Visiting Nurses, SASH, Council on Aging, VCCI, RMH, various support groups, and any other member of the healthcare team or community stakeholders as necessary.
- Assist patients identified as needing intense care/chronic disease management with individualized programs on an ongoing basis.
- Develop a panel of patients who need care management services by creating a care plan to improve their health outcomes (e.g., CCM, ACO, CM).
- Actively participate and collaborate in managing patients that require home health visits.
- Assist with transitions of care for patients moving to or from home, hospital, rehab, or other facilities, including non-care managed patients.
- Complete designated self-chart audits.
- Comply with required expectations for consistent documentation of care management services provided.
- Provide follow-up care for patients discharged from the emergency room, inpatient discharges, and inpatient readmissions.
- Specialize in geriatrics, assisting elderly patients with challenges through individualized programs and ongoing care management.
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.
- Experience in using a variety of electronic medical record and ability to learn other systems, basic keyboarding skills and email communication.
How we support you
- Work Life Balance
- Generous Time Off
- Medical, dental, and vision insurance.
- Health savings account option.
- Robust 403 (b) retirement savings plan, with employer match and 100% vesting schedule.
- Comprehensive Wellness Program.
