Nurse Care Manager

Community Health Centers of Burlington•South Burlington, VT

2d•Onsite

About The Position

The Nurse Care Manager (RN) collaborates with interdisciplinary members of the care team to deliver high-quality, coordinated, and patient-centered care across the continuum. This role supports individuals, families, caregivers, and support systems through proactive, relationship-based care management that emphasizes improved health outcomes, patient experience, and efficient resource utilization. The Nurse Care Manager focuses on both episodic and longitudinal care management for patients with complex medical, behavioral health, and social needs. Patient identification is driven by risk stratification, clinical workflows, and value-based care initiatives, including those aligned with Accountable Care Organization (ACO) priorities. The Nurse Care Manager functions as a key clinical partner within the team-based care model, supporting providers in managing high-risk populations, reducing avoidable utilization of emergency services, and advancing quality, safety, and equity outcomes.

Requirements

Associate's degree.
2 years of outpatient clinical experience required.
Possess a professional, positive, team-oriented attitude
Ability to communicate well with others through written and verbal interpersonal communication skills
Ability to perform routine assignments independently
Demonstrate attention to detail and organizational skill
Demonstrate strong assessment skills (professional, situational & clinical)
Possess knowledge/expertise related to Care Management and coordination
Ability to lead and engage in Motivational Interviewing techniques
Possess basic computer skills and experience with Office product suite (Outlook, Word, Excel)
Demonstrate knowledge and proficiency with EHR/Practice Management, and Population Health Management software systems
Possess knowledge/expertise related to concepts of Population Health Management
Proficiency in analyzing, stratifying, and utilizing data to drive priorities
Ability to multi-task and prioritize with minimal direction
Demonstrate critical thinking skills and emotional intelligence in the workplace
Demonstrate patient-centric model of care delivery and customer service
Uphold the mission, values, and principles of the organization
Create and maintain a positive, team-based culture
Registered Nurse licensed in the State of Vermont (without restrictions)
Good standing with Vermont State Board of Nursing.

Responsibilities

Using a population health framework, the Nurse Care Manager conducts comprehensive assessments, develops and implements individualized care plans, facilitates care transitions, and addresses barriers to care, including social drivers of health.
The role emphasizes patient engagement, self-management support, and coordination across clinical and community-based services.
The Nurse CM will partner with the clinical and case management teams to ensure safe, timely, efficient and effective transitions of care for patients – both within and outside of the primary care practice.
The Nurse CM will Perform initial and ongoing assessments covering behavioral health needs (depression, substance use), functional status, and social drivers of health.
The Nurse CM will demonstrate in-depth knowledge of local and regional community resources addressing social needs and ability to effectively connect patients to services through coordinated referrals, eligibility support, and follow-up to ensure access and engagement.
Uses professional skills to the best of their ability
Provides a positive patient-centered experience for every patient
Considers safety of patients and works to help provide a safe environment
Maintains a current up-to-date knowledge of all policies and procedures
Works to create an efficient, highly productive environment
Follows and optimizes concepts of Patient Centered Care Delivery
Works collaboratively with all staff, providers and leadership
Engages others as part of a team-oriented philosophy
The Nurse CM will work with practice leadership, providers, clinical staff and ancillary care teams, as well as with patients, families/caregivers, and community partners in order to achieve healthcare goals and maintain open lines of communication across the care team.