Community Health Team Supervisor / Chronic Care Coordinator II

This is a grant funded position paid by the Blueprint.

Position Allocation:

This is a combined position consisting of approximately 50% Community Health Team supervision and leadership and 50% direct chronic care coordination and complex case management . Allocation may be adjusted based on patient needs, staffing, operational priorities, and organizational initiatives. Both functions are essential and will be included in performance evaluations.

Who we Are:

Nestled into the most northern part of Vermont, North Country Hospital is a community-focused 25 bed critical access hospital, where we prioritize the well-being of our neighbors. North Country Hospital is more than just a healthcare provider; we are a vital part of the community, working together to build a healthier future. Our patient’s health is our priority, and we go above and beyond to care in every way possible.

Position Statement

The Community Health Team Supervisor / Chronic Care Coordinator II provides team leadership, operational oversight, direct patient care coordination, and complex case management. The position supports integrated care across hospital services, primary and specialty care practices, nursing facilities, rehabilitation centers, and community-based organizations.

Approximately 50% of the position is dedicated to supervising and coordinating the day-to-day operations of the Community Health Team, supporting staff development, monitoring team performance, collaborating on quality improvement initiatives, and promoting effective care transitions across the healthcare continuum.

The remaining 50% focuses on short-term case management and chronic care coordination for patients with complex medical and psychosocial needs. Responsibilities include patient assessments, individualized care planning, medication and follow-up review, chronic disease education, and coordination of healthcare and community resources.

The position collaborates with patients, families, providers, hospital leadership, and community partners to improve continuity of care, reduce avoidable hospital utilization and readmissions, and promote positive patient outcomes.

Essential Functions, Duties, and Responsibilities

• Community Health Team Supervision and Leadership - 50%
• Coordinate daily operations of the Community Health Team and ambulatory care management services.
• Provide leadership, coaching, and support to promote staff accountability, professional development, and quality patient care.
• Identify staff training needs and support ongoing education and development.
• Establish performance goals, monitor team outcomes, and identify opportunities for improvement.
• Monitor employee time and attendance in accordance with organizational policies.
• Facilitate collaboration among hospital teams, primary and specialty care practices, and community agencies.
• Represent North Country Hospital in partnerships with healthcare and community organizations.
• Collaborated with Manager of Population Health, practice management, and clinical leadership on quality improvement initiatives.
• Review outcomes, utilization data, and workflows to identify care gaps and improve efficiency.
• Support initiatives that strengthen care transitions, reduce avoidable readmissions, and promote appropriate utilization of services.
• Promote evidence-based care management practices and ensure team responsibilities align with patient needs and organizational priorities.
• Direct Chronic Care Coordination and Complex Case Management - 50%
• Provide short-term case management for patients with chronic conditions, complex medical needs, and psychosocial barriers.
• Conduct and document patient and family interviews, clinical and psychosocial assessments, and care planning interventions.
• Develop and monitor individualized care plans in collaboration with patients, families, providers, and multidisciplinary teams.
• Identify barriers to care and coordinate resources addressing transportation, healthcare access, financial concerns, and social service needs.
• Coordinate transitions between hospital, nursing facilities, rehabilitation centers, primary and specialty care, and other outpatient settings.
• Review medications, treatment plans, and follow-up recommendations with patients in collaboration with the primary care team and prescribing providers.
• Provide medication-related and chronic disease education within professional licensure and organizational guidelines.
• Educate patients and families on disease management, treatment adherence, symptom monitoring, and complication prevention.
• Connect patients and families with appropriate healthcare providers, social service agencies, and community resources.
• Support advance care planning, advance directives, and end-of-life care coordination.
• Facilitate timely post-discharge follow-up and address care gaps that may contribute to emergency department visits or readmissions.
• Document assessments, care plans, interventions, referrals, education, and follow-up in the electronic medical record.
• Collaborate with providers and practice managers to address patient needs and support practice-based quality improvement.

Knowledge, Skills and Abilities

• Must possess and maintain a current, unrestricted Registered Nurse (RN) license or Licensed Practical Nurse license (LPN) issued by the State of Vermont.
• Previous experience working in a primary care office.
• Previous experience working with local and state social services and health care agencies.
• Experience working with care management teams is a plus.