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 Community Health Care Manager will facilitate and ensure a structured, thoughtful, planned and integrated plan of care and process for all Community Health patients that will support and maximize patients in both the inpatient and outpatient environment.

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FUNCTIONS OF THE POSITION:

• Collaborate and coordinate care with any potential post discharge concern or barrier that has been identified.
• Provide follow-up phone calls post discharge and will partner with the healthcare team.
• Assure that hospital discharged patients have adequate education and knowledge of their medication lists through medication reconciliation.
• Referrals will be made to the Care Manager whenever a primary nurse or provider identifies a complex or high-risk patient. This will be irrespective of whether the patient has been hospitalized.
• Will work with Visiting Nurses, SASH, Council on Aging, VCCI, RMH; various support groups and any other member of the healthcare team as necessary.
• Develop a panel of patients to include patients that have been identified as those that will benefit from CCM (Chronic care management) utilizing the identified workflows and processes for the CCM Medicare program.
• The Care Manager will assist providers, patients, Community Health staff and Skilled Nursing facilities (SNF) staff with plan of care during extended care facility inpatient stays.

SKILLS REQUIRED FOR SUCCESS:

• Current Vermont RN license
• Prior experience working in a nursing position required
• Prior case management experience in a similar outpatient setting preferred
• CPR Certification

HOW WE SUPPORT YOU:

• Medical insurance.
• Dental insurance.
• Health savings account option.
• 403 (b) retirement savings plan.