Clinical Care Manager

Gifford Health Care is seeking a Community Health Team Spoke Nurse Care Manager to join our Vermont Blueprint for Health team. In this role, you will provide comprehensive care management and care coordination services for patients with complex health, behavioral health, and social needs within our Addiction Medicine program.

Working collaboratively with patients, providers, and community partners, you will help individuals access appropriate healthcare services, improve health outcomes, and build self-management skills. The Care Manager ensures patients maintain an active relationship with a Primary Care Provider (PCP) and facilitates access to high-quality, evidence-based healthcare services, while helping patients connect with community-based programs, resources, and benefits that support overall health and well-being.

As part of Vermont#s Hub and Spoke model, the Care Manager provides comprehensive care management, care coordination, health promotion, and transitional care services following emergency department visits or hospitalizations. This role also provides individual and family support, facilitates referrals to community services, Community Health Team programs, and Primary Care Providers, and empowers patients to develop effective self-management skills.

Areas of focus may include infectious disease prevention and education, tobacco cessation, pregnancy and prenatal support, parenting skills, co-occurring mental health conditions, dental health, nutrition, personal hygiene, and chronic disease management, including hypertension, diabetes, obesity, coronary artery disease, chronic pain, and depression.

Working closely with healthcare providers, community agencies, and the broader Community Health Team, this role supports continuity of care and helps patients successfully navigate healthcare and social service systems. Confidentiality and adherence to Gifford Health Care policies and procedures are essential.

Requirements

Current Vermont license as an LPN or RN,# or other qualifying healthcare professional as approved under Vermont Blueprint for Health Community Health Team standards. Experience in care management, care coordination, behavioral health, chronic disease management, or community-based services preferred. Strong communication, motivational interviewing, and patient engagement skills.

Ability to work independently and collaboratively within an interdisciplinary team. Gifford Health Care offers competitive compensation and a comprehensive benefits package. Our Total Rewards package includes, but is not limited to: Competitive wages Onsite parking# 403b retirement plan Health plans including dental and vision insurance Tax-saving flexible spending accounts Health Savings Plan with employer contribution Long and short-term disability insurance Tuition Reimbursement Employee Assistance Program Life Insurance Regular performance reviews Learning opportunities EOE