LPN/RN Care Manager - Mettowee

Community Health Centers of the Rutland Region; Vermont; Vor Ort; USD 36.000 - 55.000; Vollzeit

Benefits dieser Stelle

Work Life Balance

Generous Time Off

Medical, Dental, Vision Insurance

Health Savings Account

403(b) Retirement Plan

Zusammenfassung

Community Health Centers of the Rutland Region is seeking an LPN/RN Care Manager for the Mettowee area in West Pawlet, VT. The role focuses on coordinating care for patients with complex needs, following risk stratification, and supporting transitions between inpatient and outpatient settings.

The Care Manager will work with patients, families, and the care team to navigate medical and behavioral health needs, emphasizing social determinants of health and community resources.

Qualifikationen

• CPR certification is required.
• Nursing experience in outpatient setting preferred.
• Experience using EMR/EHR systems and basic keyboard/email skills.

Aufgaben

• Provide follow-up care to identified patients based on complexity and social determinants of health.
• Coordinate care with post-discharge resources and barriers.
• Provide transitional care for high-risk patients after discharge.
• Ensure patients understand their medications after hospital discharge.

Kenntnisse

CPR Certification

Nursing Experience

Case Management

EMR/EHR Systems

Ausbildung

RN or LPN License

Tools

EMR Systems

Jobbeschreibung

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.

LPN/RN Care Manager - Mettowee

WEST PAWLET, VT, US

Salary Range: $25.98 To $40.17 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 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.
• 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:

• 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.

RN Pay Scale: 33.05 - 53.25

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.