Chronic Care Coordinator
North Country Hospital | Newport, VT
Statement of Purpose
The Care Coordinator is responsible for managing and coordinating the care for high risk patients with or at risk of chronic conditions who receive primary care from the medical practices of NCH. This includes complex individuals with multiple chronic illnesses, behavioral health comorbidities and/or complex social needs. This position provides direct services to high risk patients and/or families and focuses on coordinating care across the entire care continuum, advancing care plan progress, providing on-going patient self- management supports and fulfilling other complex needs as they arise. The Care Coordinator provides interventions and plans of care to meet a variety of social/health needs in coordination with providers and a multidisciplinary team utilizing available community resources. The Care Coordinator serves as the main point of contact for patients' providers across a variety of care settings, aims to better manage patients in the ambulatory setting and reduce avoidable use of the Emergency Department.
Maintains current or Vermont RN license and a Bachelor's degree or Vermont LICSW or equivalent education/experience in care management or social services field
1-2 years' experience in a primary care office preferred but not required.
1-2 years of demonstrated abilities to multi-task, work in a fast paced medical environment, provide crisis management, successful communication and organizational skills.
Location-Primary Care Newport.