Geriatric Care Manager - RN

Community Health Centers of the Rutland Region; Rutland, Northern (VT, KY); Hybrid; USD 46,000 - 73,000; Full time

Job summary

Community Health Centers of the Rutland Region in Rutland, VT is seeking a Geriatric Care Manager - RN to coordinate care for high‑risk patients across inpatient and outpatient settings, guiding transitions and ensuring continuity of care.

You will collaborate with patients, families and the care team to address social determinants of health, educate on medications, and arrange timely follow‑ups and face‑to‑face visits when needed.

Qualifications

• CPR certification required.
• Nursing experience in outpatient setting preferred.
• Experience with electronic medical records and ability to learn new systems.

Responsibilities

• Provide follow-up care to identified patients based on complexity and social determinants.
• Collaborate and coordinate care for post-discharge barriers.
• Provide transitional care post-discharge for risk stratified patients.
• Ensure education on medications for discharged patients.
• Set telephone follow-up frequency based on patient needs.
• Identify barriers to care and connect patients with resources.
• Determine need for in-person visits.

Skills

CPR Certification

Nursing experience

Case management experience

EMR systems experience

Education

RN license

Tools

Electronic Medical Records (EMR) software

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Geriatric Care Manager - RN

Rutland, VT, US

8 days ago Requisition ID: 2017

Salary Range: $33.05 To $53.17 Hourly

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 health 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:

• 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.