Start here at Hartford HealthCare and be part of something betterEvery day more than Hartford HealthCare colleagues come to work with one thing in common Pride in what we do We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford HealthCare Medical Group is one of the largest medical practices in New England with multiple locations throughout Connecticut and Rhode Island We consist of a team of professionals ranging from Medical Assistants to Physician Assistants and everything in between Our physician led medical group enjoys an excellent reputation with patients and the medical community offering primary care urgent care and more than different specialtiesAt Hartford HealthCare Medical group we offerSupportive environment to promote professional and interpersonal development and growthTuition Reimbursement up to after six months of employment and up to tuition discounts with partnering institutions for colleagueANDdependentsMedical dental and vision coverage optionsGenerous PTO to promote worklife balanceEmployee assistance and wellness programs including astrong focus on promoting mental healthDiscounts on services products and optional coverages ndash movie tickets pet insurance travel and moreJOB SUMMARYThe ICP Community Care Manager is a healthcare professional position working as a member of the ICP Community Care Management team The ICP Community Care Manager facilitates transitions as patients move from one level of care to another ensuring that uninterrupted quality care as well as providing ongoing education and diseased management for ICP attributed patients with chronic conditions They are responsible for providing support and performing duties in a manner that ensures effective and efficient customer service and patient care This position is ideal for someone with a minimum Master of Social Work or minimum Bachelor of Science in Nursing with a healthcare professional background that is passionate about transforming healthcare and assisting patients in meeting their health goalsKey Areas of ResponsibilitybullPerforms transition of care services for ICP attributed patients admitted to acute inpatient settings skilled nursing facilities and other post acute facilitiesbullParticipates in discharge planning meetings throughout patientrsquos inpatient acuteSkilled Nursing Facility SNFLong Term Acute Care Hospital LTACH stay as appropriatebullPartners with inpatient care coordination team to address barriers to discharge including Social Determinants of Health needs other biopsychosocial related needs andor healthcare related barriers while also providing timely communication back to the patientrsquos primary care providerbullCollaborates with other HHC system partners upon patientrsquos discharge from acute inpatient skilled nursing facility and other post acute facility setting to the communitybullPartners with Skilled Nursing Care Coordinators Resource Coordinators ICP Clinical Pharmacists Primary Care Behavioral Health Clinicians and homecare partners to support patients across the care continuumbullReviews and identifies at risk patients ED utilization high risk score care gaps etc for proactive outreach and longitudinal care managementbullCollaborates with patient caregiver providers and additional care team members to develop longitudinal plan of care including development of a care plan appropriate referrals and community supportsbullIdentifies resources within HHC system and larger community to address patient care needsbullProvides education for patients families community and other professionals regarding disease prevention impact of illness and advocacy for benefits and health maintenancebullParticipates in continuous improvement opportunities through workgroups collaborative pilots and system initiative councils Contributes to ongoing development of the care management model across the continuum through valuable input and constructive feedbackStart here at Hartford HealthCare and be part of something betterEvery day more than Hartford HealthCare colleagues come to work with one thing in common Pride in what we do We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford HealthCare Medical Group is one of the largest medical practices in New England with multiple locations throughout Connecticut and Rhode Island We consist of a team of professionals ranging from Medical Assistants to Physician Assistants and everything in between Our physician led medical group enjoys an excellent reputation with patients and the medical community offering primary care urgent care and more than different specialtiesAt Hartford HealthCare Medical group we offerSupportive environment to promote professional and interpersonal development and growthTuition Reimbursement up to after six months of employment and up to tuition discounts with partnering institutions for colleagueANDdependentsMedical dental and vision coverage optionsGenerous PTO to promote worklife balanceEmployee assistance and wellness programs including astrong focus on promoting mental healthDiscounts on services products and optional coverages ndash movie tickets pet insurance travel and moreJOB SUMMARYThe ICP Community Care Manager is a healthcare professional position working as a member of the ICP Community Care Management team The ICP Community Care Manager facilitates transitions as patients move from one level of care to another ensuring that uninterrupted quality care as well as providing ongoing education and diseased management for ICP attributed patients with chronic conditions They are responsible for providing support and performing duties in a manner that ensures effective and efficient customer service and patient care This position is ideal for someone with a minimum Master of Social Work or minimum Bachelor of Science in Nursing with a healthcare professional background that is passionate about transforming healthcare and assisting patients in meeting their health goalsKey Areas of ResponsibilitybullPerforms transition of care services for ICP attributed patients admitted to acute inpatient settings skilled nursing facilities and other post acute facilitiesbullParticipates in discharge planning meetings throughout patientrsquos inpatient acuteSkilled Nursing Facility SNFLong Term Acute Care Hospital LTACH stay as appropriatebullPartners with inpatient care coordination team to address barriers to discharge including Social Determinants of Health needs other biopsychosocial related needs andor healthcare related barriers while also providing timely communication back to the patientrsquos primary care providerbullCollaborates with other HHC system partners upon patientrsquos discharge from acute inpatient skilled nursing facility and other post acute facility setting to the communitybullPartners with Skilled Nursing Care Coordinators Resource Coordinators ICP Clinical Pharmacists Primary Care Behavioral Health Clinicians and homecare partners to support patients across the care continuumbullReviews and identifies at risk patients ED utilization high risk score care gaps etc for proactive outreach and longitudinal care managementbullCollaborates with patient caregiver providers and additional care team members to develop longitudinal plan of care including development of a care plan appropriate referrals and community supportsbullIdentifies resources within HHC system and larger community to address patient care needsbullProvides education for patients families community and other professionals regarding disease prevention impact of illness and advocacy for benefits and health maintenancebullParticipates in continuous improvement opportunities through workgroups collaborative pilots and system initiative councils Contributes to ongoing development of the care management model across the continuum through valuable input and constructive feedbackMinimum RequirementsEducationMaster of Social Work MSW or Bachelor of Science in Nursing BSNLicensure Certification RegistrationMental Health First Aid Certification within st year of hireIf RN CT RN license requiredLanguage SkillsbullAble to read speak write EnglishWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balanceMinimum RequirementsEducationMaster of Social Work MSW or Bachelor of Science in Nursing BSNLicensure Certification RegistrationMental Health First Aid Certification within st year of hireIf RN CT RN license requiredLanguage SkillsbullAble to read speak write EnglishWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance