RN Care Manager — Transitional & Coordinated Care

About CHCRR; Brandon (VT); On-site; USD 60,000 - 85,000; 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,

Job summary

Community Health in Vermont seeks a Care Manager to support patients identified through risk stratification, guiding them through medical, behavioral health, and social services as they move among inpatient, outpatient, and home settings. You will coordinate care with families, care teams, and community resources to ensure smooth transitions.

Active Vermont RN or LPN license and CPR certification are required; prior outpatient case management experience is preferred.

Qualifications

• Active Vermont RN or LPN license and CPR certification required.
• Experience in nursing and case management in outpatient settings preferred.
• Ability to coordinate care across multiple care settings and teams.

Responsibilities

• Provide follow-up care to identified patients based on level of complexity and social determinants.
• Coordinate care with post-discharge concerns or barriers identified.
• Provide transitional care post-discharge from outpatient or inpatient venues.
• Ensure education and knowledge of patients' medication lists after hospital discharge.
• Determine frequency of telephone encounters based on patient needs.
• Identify barriers to care and reach out to appropriate resources.
• Determine when a face-to-face visit is needed.

Skills

Nursing experience

Care coordination

Communication skills

CPR Certification

Education

Vermont RN or LPN license

Tools

Electronic Medical Records (EMR) systems

Job description

Community Health in Vermont seeks a Care Manager to support patients identified through risk stratification, guiding them through medical, behavioral health, and social services as they move among inpatient, outpatient, and home settings. You will coordinate care with families, care teams, and community resources to ensure smooth transitions.

Active Vermont RN or LPN license and CPR certification are required; prior outpatient case management experience is preferred.