Care Manager — Transitional Health & Care Coordinator

Community Health Centers of the Rutland Region; Rutland (VT); Hybrid; USD 37,000 - 73,000; Full time

Benefits offered by this job

Work Life Balance

Generous Time Off

Medical, dental, and vision insurance

Health savings account option

Robust 403(b) retirement savings plan,

Comprehensive Wellness Program

Job summary

Community Health Centers of the Rutland Region in Rutland, VT seeks a Care Manager – RN or will consider LPN – to coordinate follow-up care for at-risk patients transitioning across care settings.

You will work with care teams to address social determinants of health, arrange post-discharge followups, and ensure patients understand medications.

The position offers a meaningful role in improving local community health with competitive pay and benefits.

Qualifications

• Current Vermont RN or LPN license.
• CPR certification required.
• Experience in nursing; prior case management in outpatient setting preferred.
• Experience with electronic medical records and basic keyboarding / email communication.

Responsibilities

• Provide follow-up care to identified patients based on complexity and social determinants of health.
• Coordinate care with post-discharge concerns or barriers identified.
• Provide transitional care to risk-stratified patients post-discharge.
• Ensure discharged patients understand their medication lists.
• Determine frequency of telephone encounters based on patient need.
• Identify barriers to care and reach out to appropriate resources.
• May determine that a patient requires a face-to-face visit.

Skills

CPR Certification

Nursing experience

EMR systems proficiency

Keyboarding & email skills

Education

Vermont RN or LPN license

Tools

EMR systems

Job description

Community Health Centers of the Rutland Region in Rutland, VT seeks a Care Manager – RN or will consider LPN – to coordinate follow-up care for at-risk patients transitioning across care settings.

You will work with care teams to address social determinants of health, arrange post-discharge followups, and ensure patients understand medications.

The position offers a meaningful role in improving local community health with competitive pay and benefits.