Start here at Hartford HealthCare and be part of something better!   Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do. We invite you to become part of Connecticut’s most comprehensive healthcare network.   *Hartford 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 30 different specialties. At Hartford HealthCare Medical group we offer: * Supportive environment to promote professional and interpersonal development and growth * Tuition Reimbursement up to $5,250.00 after six months of employment and up to 40% tuition discounts with partnering institutions for colleague AND dependents * Medical, dental and vision coverage options * Generous PTO to promote work/life balance * Employee assistance and wellness programs including a strong focus on promoting mental health * Discounts on services, products and optional coverages – movie tickets, pet insurance, travel and more!   *JOB SUMMARY* The 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 goals. *Key Areas of Responsibility* • Performs transition of care services for ICP attributed patients admitted to acute inpatient settings, skilled nursing facilities and other post-acute facilities • Participates in discharge planning meetings throughout patient’s inpatient acute/Skilled Nursing Facility (SNF)/Long-Term Acute Care Hospital (LTACH) stay, as appropriate • Partners with inpatient care coordination team to address barriers to discharge including: Social Determinants of Health needs, other biopsychosocial related needs and/or healthcare related barriers, while also providing timely communication back to the patient’s primary care provider • Collaborates with other HHC system partners upon patient’s discharge from acute inpatient, skilled nursing facility and other post-acute facility setting to the community • Partners with Skilled Nursing Care Coordinators, Resource Coordinators, ICP Clinical Pharmacists, Primary Care Behavioral Health Clinicians and homecare partners to support patients across the care continuum • Reviews and identifies at risk patients (ED utilization, high risk score, care gaps, etc) for proactive outreach and longitudinal care management • Collaborates 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 supports • Identifies resources within HHC system and larger community to address patient care needs • Provides education for patients, families, community, and other professionals regarding disease prevention, impact of illness and advocacy for benefits and health maintenance • Participates 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 feedback. *Minimum Requirements* *Education:* Master of Social Work (MSW), or Bachelor of Science in Nursing (BSN) *Licensure, Certification, Registration* Mental Health First Aid Certification within 1st year of hire If RN: CT RN license required *Language Skills* • Able to read, speak, write English With 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 work/life balance. **Job:** **Case Management* **Organization:** **Hartford HealthCare Medical Group* **Title:** *ICP Community Care Manager * **Location:** *Connecticut-Wethersfield-1290 Silas Deane Hwy Wethrsfld (10181)* **Requisition ID:** *25160490*