PHSO Care Manager - Hybrid

UVM Medical Center • Berlin, VT

7d • $36 - $54 • Hybrid

About The Position

The PHSO Care Manager delivers an innovative, patient-centered care management model for primary care patients who may benefit from coordinated support to improve outcomes. The i ndividual stepping into this role will need to think creatively and “outside the box,” using nuanced, innovative outreach strategies in collaboration with community partners and across settings. This role serves as a connector between patients, interdisciplinary teams, payers, and community organizations to reduce barriers to care, improve wellness, and support population health efforts. The role also participates in mentoring, staff development, and process improvement within the department and across the Network.

Requirements

• Master's in social work (MSW) from an accredited school of social work required. LICSW preferred, or Master’s degree in a Health or Human Services field required (licensure preferred), or Current RN licensure (BSN strongly encouraged per UVMH initiative).
• Case management accreditation (CCM, ACM, ANCC) preferred or willingness to obtain upon hire.
• 2–3 years clinical experience in a healthcare setting.
• Care Management or Care Coordination experience required.
• Knowledge of case management practice standards and payer/regulatory requirements.
• Understanding of population needs, health disparities, and community resources.
• Strong verbal and written communication skills.
• Demonstrated ability to build trusting, culturally aware relationships.
• Familiarity with team dynamics and interdisciplinary collaboration.

Responsibilities

• Clinical Assessment & Care Management Conduct comprehensive medical and psychosocial assessments, including health behaviors, cultural factors, financial considerations, functional status, and legal issues. Implement screenings, document assessment findings, and develop individualized plans of care. Identify and coordinate resources across hospital, primary care, and community settings. Facilitate care conferences, establish goals, and evaluate progress. Recommend safe, cost‑effective treatment alternatives and ensure integration of patient preferences and team input. Maintain knowledge of regulatory guidelines and case management standards.
• Patient‑Centered & Family‑Centered Care Coordination Provide care coordination that supports patient autonomy, family involvement, and culturally informed care. Tailor education to patient readiness, health literacy, and individual learning needs. Maintain knowledge of Network and community resources to address diverse patient needs. Support learning activities and contribute to the academic and training missions of Care Management.
• Interdisciplinary Collaboration & Teamwork Build trusting, respectful relationships across teams, departments, and care settings. Communicate clearly and professionally with patients, caregivers, and colleagues. Demonstrate self‑awareness, openness to feedback, and commitment to ethical practice. Work collaboratively with new and experienced staff, maintaining alignment with team and organizational goals.
• Psychosocial & Behavioral Health Intervention Assess and intervene in complex psychosocial situations involving mental health, substance use, adjustment, and grief. Identify Drivers of Utilization (DOU) and implement targeted interventions to support patient stability. Perform or facilitate assessments in cases involving abuse, neglect, domestic violence, or sexual assault. Assist care teams in understanding patient/family coping styles and dynamics influencing care. Support patients with chronic and complex conditions, coordinating with multidisciplinary providers when needed.
• Care Transition & Resource Linkage Support seamless transitions between inpatient, outpatient, and community care settings. Link patients to appropriate services, monitor engagement, and ensure warm handoffs. Collaborate with point-of-entry providers to improve continuity and reduce avoidable utilization. Track and analyze program data to support quality improvement and demonstrate program impact.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level