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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in case management and field nursing interventions for high-complexity patients, with a strong focus on patient stabilization, care coordination, and community resource navigation. Proficient in developing personalized care plans and conducting comprehensive assessments while providing clinical supervision and support to team members.
Highest-signal resume keywords
Registered Nurse (RN) LicenseCommunity Case Management ExperienceClinical AssessmentsBasic Life Support (BLS) CertificationPatient Care Coordination
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Case ManagementClinical SupervisionPatient AssessmentsCare Plan DevelopmentMedication MonitoringHealth EducationFall PreventionSDoH AssessmentsPatient Progress MonitoringDocumentation Procedures
Soft Skills
Interpersonal SkillsCommunication SkillsCritical ThinkingOrganizing SkillsAutonomous Work Ability
Tools & Technologies
Microsoft Office SuiteExcelWordPowerPointOutlook
Certifications & Qualifications
Basic Life Support (BLS) Certification
Industry Keywords
Complex Care TeamHealthcare Systems NavigationCommunity HealthSocial Services SupportPatient Care Charts
About the role
Key responsibilities & impact- Provide hyperfocused case management and field nursing interventions for highest-complexity patients
- Serve as clinical lead for the Complex Care Team
- Assess, evaluate, and coordinate efforts to stabilize highest-risk patients
- Support safe transitions from facilities to primary care teams
- Stabilize high-risk ambulatory patients and reach patients not engaged in care
- Perform assessments and develop comprehensive plans of care
- Provide clinical supervision to team members and potentially directly supervise some staff
- Partner with PCPs to draft personalized care plans
- Conduct in-house, facility, telephonic, and home visits
- Perform field nursing interventions, clinical assessments, fall prevention, SDoH assessments, medication monitoring, health education, and self-care instruction
- Coordinate initial case management assessments, patient consent, plans of care, interventions, and multidisciplinary team meetings
- Help patients navigate healthcare systems and connect with community resources
- Coordinate services and maintain communication with families and community providers
- Monitor HHA visits and outpatient services
- Assist patients and families with community and financial resources
- Collaborate with Complex Care and Clinical Strategy teams to ensure holistic care
- Perform urgent home visits under PCP direction to prevent unnecessary hospital arrivals
- Review charts and conduct final patient discharges from the program
Requirements
What you’ll need- Associate degree in Nursing required
- Valid, active Registered Nurse (RN) license in State of employment required
- Minimum of 2 years’ clinical work experience required
- Minimum of 1 year of community case management experience highly desired
- Current, valid driver’s license required
- Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required within first 90 days of employment
- Strong interpersonal and communication skills
- Critical thinking skills
- Ability to work autonomously
- Ability to monitor, assess, and record patients’ progress and adjust plans accordingly
- Ability to plan, implement, and evaluate individual patient care plans
- Knowledge of nursing and case management theory and practice
- Knowledge of patient care charts and patient histories
- Knowledge of clinical and social services documentation procedures and standards
- Knowledge of community health and social services support agencies and networks
- Organizing and coordinating skills
- Ability to communicate technical information to non-technical personnel
- Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook
- Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time
- Spoken and written fluency in English
- Ability to exercise independent judgment
Benefits
Comp & perks- Great compensation
- Comprehensive benefits
- Career development and advancement opportunities
- Work-life balance
- Opportunities to grow
- Potential eligibility for bonuses or commissions