Community Health Team Supervisor / Chronic Care Coordinator II

North Country Hospital•Newport, VT

19d

About The Position

This grant-funded position, paid by the Blueprint, combines approximately 50% Community Health Team supervision and leadership with 50% direct chronic care coordination and complex case management. The allocation may change based on patient needs, staffing, operational priorities, and organizational initiatives; both functions are essential and included in performance evaluations. The position provides team leadership, operational oversight, patient care coordination, and complex case management. It supports integrated care across hospital services, primary and specialty care practices, nursing facilities, rehabilitation centers, and community-based organizations. The supervisory portion oversees daily Community Health Team operations, staff development, team performance, quality improvement, and care transitions. The direct-care portion provides short-term case management and chronic care coordination for patients with complex medical and psychosocial needs, including assessments, individualized care planning, medication and follow-up review, chronic disease education, and coordination of healthcare and community resources. The role collaborates with patients, families, providers, hospital leadership, and community partners to improve continuity of care, reduce avoidable hospital utilization and readmissions, and promote positive patient outcomes. North Country Hospital is a community-focused 25-bed critical access hospital in northern Vermont.

Requirements

Must possess and maintain a current, unrestricted Registered Nurse (RN) license or Licensed Practical Nurse (LPN) license issued by the State of Vermont.
Previous experience working in a primary care office.
Previous experience working with local and state social services and healthcare agencies.

Nice To Haves

Experience working with care management teams.

Responsibilities

Coordinate daily operations of the Community Health Team and ambulatory care management services.
Provide leadership, coaching, and support to promote staff accountability, professional development, and quality patient care.
Identify staff training needs and support ongoing education and development.
Establish performance goals, monitor team outcomes, and identify opportunities for improvement.
Monitor employee time and attendance in accordance with organizational policies.
Facilitate collaboration among hospital teams, primary and specialty care practices, and community agencies.
Represent North Country Hospital in partnerships with healthcare and community organizations.
Collaborate with the Manager of Population Health, practice management, and clinical leadership on quality improvement initiatives.
Review outcomes, utilization data, and workflows to identify care gaps and improve efficiency.
Support initiatives that strengthen care transitions, reduce avoidable readmissions, and promote appropriate utilization of services.
Promote evidence-based care management practices and align team responsibilities with patient needs and organizational priorities.
Provide short-term case management for patients with chronic conditions, complex medical needs, and psychosocial barriers.
Conduct and document patient and family interviews, clinical and psychosocial assessments, and care planning interventions.
Develop and monitor individualized care plans with patients, families, providers, and multidisciplinary teams.
Identify barriers to care and coordinate resources addressing transportation, healthcare access, financial concerns, and social service needs.
Coordinate transitions between hospitals, nursing facilities, rehabilitation centers, primary and specialty care, and other outpatient settings.
Review medications, treatment plans, and follow-up recommendations with patients in collaboration with primary care teams and prescribing providers.
Provide medication-related and chronic disease education within professional licensure and organizational guidelines.
Educate patients and families on disease management, treatment adherence, symptom monitoring, and complication prevention.
Connect patients and families with healthcare providers, social service agencies, and community resources.
Support advance care planning, advance directives, and end-of-life care coordination.
Facilitate timely post-discharge follow-up and address care gaps that may contribute to emergency department visits or readmissions.
Document assessments, care plans, interventions, referrals, education, and follow-up in the electronic medical record.
Collaborate with providers and practice managers to address patient needs and support practice-based quality improvement.