Geriatric Care Manager - RN

About CHCRR; Rutland (VT); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Work Life Balance

Generous Time Off

Medical Insurance

Dental Insurance

Vision Insurance

Health Savings Account

403(b) Plan

Wellness Program

Job summary

Community Health in Rutland, VT is seeking a Care Manager to support patients identified through risk stratification, assisting with medical, behavioral health, and social needs across care settings.

You will coordinate with care teams, families, and community resources to educate, follow up, and arrange timely visits while reducing barriers to care and improving outcomes. This is a full-time, team-focused role in Rutland with strong benefits.

Qualifications

• Current Vermont RN/LPN license.
• CPR Certification.
• Prior nursing experience; case management in outpatient setting preferred.
• Experience with EMR systems and ability to learn new software.

Responsibilities

• Provide follow-up care to identified patients based on complexity and social determinants of health.
• Coordinate care with post-discharge concerns or barriers.
• Provide transitional care post-discharge from outpatient or inpatient venues.
• Ensure patients understand their medication lists after discharge and follow education plans.
• Determine frequency of telephone encounters based on patient need.
• Identify barriers to care and connect patients to appropriate resources.
• Facilitate face-to-face visits when necessary.

Skills

Current Vermont RN/LPN license

CPR Certification

Nursing experience with case mgmt

EMR proficiency

Tools

EMR systems

Job description

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.
• 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.