CARE MANAGER – Pediatrics
Community Health Centers of the Rutland Region
This is a Full-time position in Rutland, VT posted September 14, 2021.
The Pediatric Care Manager will adhere to standards of care for children including, but not limited to, developmentally disabled, medically fragile, and foster care populations.
Develops a patient centered plan of care through collaboration with the patient (as age appropriate), family, appointed guardian and the multi-disciplinary health care team (pediatricians, specialists, school or facility social workers and home or community-based providers) to maximize the pediatric patients functional capacity and ensure their safety with coordinated care efforts.
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.
POSITION SUMMARY: * Will provide follow-up care to all identified patients based on level of complexity, social determinants of health and the identified stratification tool.* Will collaborate with the PCP regarding follow-up care and potential post discharge concerns or barriers that have been identified.* Will provide follow-up phone calls post discharge and will partner with the healthcare team.* Will assure that hospital discharged patients have adequate education and knowledge of their medication lists through medication reconciliation.* Referrals will be made to the Care Manager whenever a primary nurse or provider identifies a complex or high-risk patient.
This will be irrespective of whether the patient has been hospitalized.* Will work with Visiting Nurses, School Districts, Community Health team Social Workers, Rutland Mental Health (VT), Dept.
of Child and Family Services, various support groups and any other member of the healthcare team as necessary.* Will provide home visits when necessary.* Will develop a panel of patients who need care management services by creating a care plan to improve their health outcomes (i.e., ACO, CM).* The Care Manager will assist providers, patients, Community Health staff with plan of care during extended care facility inpatient stays.* Will complete designated self-chart audits and comply with required expectations for consistent documentation of care management services provided.
KNOWLEDGE, EDUCATION AND SKILL REQUIREMENTS: * Current Vermont RN license* Prior experience working in a nursing position required* Prior case management experience in a similar outpatient setting preferred* CPR Certification
