Community Care Manager - Hybrid

UVM Health is hiring a Community Care Manager to join their team at UVM Health- Alice Hyde Medical Center!

• The Community Care Manager will use our current Working to Reduce Admissions Program (WRAP) model to work with patients accessing the emergency room at UVM Health- Alice Hyde Medical Center in Malone, NY.

• This is a hybrid role with work location divided between AHMC Emergency Department, community, and remote (home) office.

• This position is part time with 40 scheduled bi-weekly hours.

JOB DESCRIPTION

Our Community Care Manager coordinates and delivers an innovative approach to identified patients eligible for WRAP (Working to Reduce Admissions Program). They promote effective utilization and monitoring of health care resources; and assume a critical role beside and in alignment with the interdisciplinary teams to achieve optimal patient-centered, clinical, and resource outcomes. They are responsible for managing the WRAP Population through the WRAP program and process in alignment with the programmatic policies and procedures. Actively participates in mentorship, training, and process improvement within their assigned organization and throughout UVMH.

CORE COMPETENCIES AND SKILLS

1. Clinical Expertise & Case Management

• Strong knowledge of care management standards and evidence-based practices.

• Experience in care coordination and managing complex patient populations.

• Ability to assess and intervene in psychosocial, mental health, and chronic care situations.

• Familiarity with Medicare, Medicaid, and insurance structures.

2. Communication & Interpersonal Skills

• Excellent verbal and written communication.

• Ability to build honest, trusting relationships with patients, families, and interdisciplinary teams.

• Cultural competence and sensitivity to diverse populations.

3. Critical Thinking & Problem Solving

• Skilled in identifying Drivers of Utilization (DOU) and proposing alternative care plans.

• Ability to assess risk, manage transitions of care, and coordinate community resources.

• Data-driven decision-making and program evaluation.

4. Teamwork & Collaboration

• Works effectively within interdisciplinary teams including pharmacists, care coordinators, and social agencies.

• Promotes a culture of teamwork, respect, and ethical practice.

• Supports mentorship and training initiatives.

5. Professionalism & Accountability

• Upholds organizational mission, values, and standards of excellence.

• Maintains confidentiality and complies with regulatory requirements (e.g., HIPAA).

• Demonstrates integrity, fairness, and commitment to continuous improvement.

6. Technical & Regulatory Knowledge

• Understanding of clinical guidelines, legal issues, and compliance standards.

• Proficient in documentation and use of care management systems.

• Maintains up-to-date knowledge of community and network resources.

EDUCATION

Master's in Social Work (MSW) from an accredited school of social work. LICSW preferred.

OR

Nursing Pathway:

Current RN licensure or compact licensure recognized by the State of Vermont required.

OR

Master's degree from an accredited institution in a Health or Human Services field. Licensure preferred.

Case management accreditation by a nationally recognized accrediting body for case management (examples: CCM, ACM or ANCC certifications), preferred; or commitment to obtain upon hire.

EXPERIENCE

2-3 years of clinical experience in a healthcare setting (or equivalent)

Care Management/Care Coordination experience required.