Geriatrics Care Manager - RN

Community Health Centers of the Rutland Region • Rutland Town, VT

3h

About The Position

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 care to another.

Requirements

• Current Vermont RN license.
• 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.

Nice To Haves

• Prior case management experience in a similar outpatient setting preferred.

Responsibilities

• 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.

Benefits

• 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.
• Comprehensive Wellness Program.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed