Community Health Centers of the Rutland Region·Rutland Town, Vermont
The Care Manager coordinates transitions of care for high-risk patients moving between inpatient and outpatient settings. They focus on reducing readmissions through follow-up care, medication education, and addressing social determinants of health.
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.
The Care Manager will collaborate with patients identified through risk stratification, focusing on emergency room and inpatient discharge follow-ups, inpatient readmissions, transitions of care, and geriatric patient health needs. The Care Manager supports patients, their families, and care team members to manage medical conditions and co-occurring behavioral health, psychological, and social determinants of health through the healthcare system. The Care Manager supports patients transitioning between healthcare practitioners, inpatient, and outpatient venues (including visiting nurses) and home settings as their condition and care needs change. This includes community resources and services that support a patient through one level of care to another.
Provide follow-up care to all identified patients based on their level of complexity, social determinants of health, and the identified stratification tool.
Collaborate and coordinate care with any potential post-discharge concerns or barriers that have been identified.
Provide transitional care to risk-stratified patients post-discharge from either outpatient or inpatient venues.
Ensure that hospital-discharged patients have adequate education and knowledge of their medication list.
Determine the frequency of telephone encounters based on specific patient needs.
Identify barriers to care (including social determinants of health) for care-managed patients and reach out to appropriate resources based on patient needs.
Determine at any time that a patient requires a face-to-face visit.
Utilize an identified schedule to follow up with their patients.
Follow up with all identified care-managed hospital discharge patients who do not keep their appointments and provide additional follow-up based on patient needs.
Make referrals to the Care Manager whenever a primary nurse or provider identifies a complex or high-risk patient, irrespective of whether the patient has been hospitalized.
Review patient lists to identify patients requiring care management services.
Work with Visiting Nurses, SASH, Council on Aging, VCCI, RMH, various support groups, and any other member of the healthcare team or community stakeholders as necessary.
Assist patients identified as needing intense care/chronic disease management with individualized programs on an ongoing basis.
Develop a panel of patients who need care management services by creating a care plan to improve their health outcomes (e.g., CCM, ACO, CM).
Actively participate and collaborate in managing patients that require home health visits.
Assist with transitions of care for patients moving to or from home, hospital, rehab, or other facilities, including non-care managed patients.
Complete designated self-chart audits.
Comply with required expectations for consistent documentation of care management services provided.
Provide follow-up care for patients discharged from the emergency room, inpatient discharges, and inpatient readmissions.
Specialize in geriatrics, assisting elderly patients with challenges through individualized programs and ongoing care management
Other Duties as assigned
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.
Candidates must hold a current Vermont LPN license and CPR certification. Prior nursing experience is required, with a preference for those who have worked in outpatient case management.
Market context
In Vermont, nursing support roles for licensed nursing assistants are often shaped by staffing needs in hospitals, long-term care, and community settings, so employers look closely for current state licensure and dependable teamwork. These roles can be competitive because candidates must meet clear credential requirements and communicate well in fast-paced care environments. Review the AI-summarized job requirements and benefits here to save research time, then confirm your Vermont LNA license and prepare an example of collaborative patient care.
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