Nurse Care Manager

COMMUNITY HEALTH CENTER OF BURLINGTON

is looking for a dedicated Nurse Care Manager

POSITION PURPOSE

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.

BASIC QUALIFICATIONS

A)

Education & Experience:

Associate's degree. 2 years of outpatient clinical experience required. B)

Knowledge, Skills & Abilities:

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 C)

Licensure, Certification or Other Requirements:

Registered Nurse licensed in the State of Vermont (without restrictions) Good standing with Vermont State Board of Nursing. The information below is intended to describe the general nature and level of work required for this position. The information is not to be construed as an exhaustive list of all responsibilities and/or duties required. Community Health Centers (CHC) reserves the right to add, remove or revise job duties and responsibilities as demanded by business needs.

ESSENTIAL DUTIES

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. Operational Excellence 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 Relationship Management 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.

NON-ESSENTIAL DUTIES

Other duties as assigned

PHYSICAL DEMANDS AND WORKING CONDITIONS

(see section VIII): Ability to lift up to 25 lbs Work is performed in an indoor, controlled environment workspace. Exposure to infectious diseases by way of patient contact.

OTHER REQUIREMENTS

Relationships:

All CHCB employees must maintain professional and effective working relationships with patients, staff and the public.

Customer Service:

All CHCB employees must provide high quality customer service to both internal customers (fellow employees), and external customers (patients and business associates) on a consistent basis.

Confidentiality:

All CHCB employees must protect the confidentiality of all patients, patient care, staff/personnel information, business and proprietary information, and financial information. Employees must read and acknowledge receipt of CHCB's Confidentiality Policy.

Compliance:

Employees must complete required trainings and adhere to the Code of Conduct, and policies in the Employee Handbook. Employees must read and acknowledge receipt of CHCB's Code of Conduct and Employee Handbook.