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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in patient care coordination, chronic disease management, and evidence-based practices while effectively collaborating with multidisciplinary healthcare teams. Proficient in conducting remote assessments and developing individualized care plans to enhance patient outcomes.
Highest-signal resume keywords
Registered Nurse (RN) LicenseBachelor of Science in Nursing (BSN)Chronic Disease Management ExperienceCare Management CertificationAmbulatory Care Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Patient Care CoordinationEvidence-Based PracticesRemote Nursing AssessmentsIndividualized Care PlansHealth CoachingScreening Criteria UtilizationData Tracking and Metrics MonitoringRoot-Cause AnalysisTelephonic TriageChronic Disease Terminology
Soft Skills
CollaborationCommunicationEducationBehavior Change SupportProblem-Solving
Tools & Technologies
Microsoft Office SoftwareTelehealth PlatformsElectronic Medical Records (EMR)Care Management Systems
Certifications & Qualifications
Care Management Certification
Industry Keywords
Continuity of CareSocial Determinants of HealthTransitional CarePatient ResourcesHealthcare Settings
About the role
Key responsibilities & impact- Provide comprehensive, time-limited services to patients and families across healthcare settings and clinicians
- Ensure continuity of care during transitions between healthcare settings
- Prevent health complications, connect patients to resources, and guide patients to the appropriate level of care
- Assess, plan, implement, and evaluate patient care using clinical expertise, technology, and evidence-based practices through telephone or digital communication
- Identify patients for proactive interventions using screening criteria, medical record review, payer models, risk scores, or referrals
- Assess medical, functional, and social conditions and develop individualized care plans, recommendations, or referrals
- Coordinate internal and external services for social determinants of health and community care
- Evaluate outcomes and modify care plans or interventions as appropriate
- Conduct remote nursing assessments and apply evidence-based protocols to determine care recommendations
- Support self-management and behavior change through health coaching, navigation, coordination, and education
- Educate healthcare team members, patients, caregivers, and families about care processes, conditions, and self-management
- Collaborate with physicians and multidisciplinary healthcare teams to ensure timely, quality care
- Participate in rounds or case conferences and consult social work, nutrition, pharmacy, rehabilitation, and behavioral health resources
- Build partnerships with hospital care management, post-acute providers, and other care managers
- Participate in system and regional process-improvement initiatives
- Conduct root-cause analysis of extended post-acute stays, inappropriate utilization, and readmissions
- Track key data elements and metrics and monitor industry, regulatory, technology, and market trends
- Promote Intermountain Health’s mission, vision, and values
Requirements
What you’ll need- Current Registered Nurse (RN) license in state of practice
- Bachelor of Science in Nursing (BSN) from an accredited institution; degree verification required
- RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion date
- Demonstrated clinical nursing experience in chronic disease management
- Familiarity with chronic disease terminology and processes
- Understanding of disease management, including treatment, length of stay, barriers to care delivery, and variations
- Basic computer skills and knowledge of Microsoft Office software
- Minimum of 2 years of nursing experience; no new grads at this time
- Care Management Certification preferred
- Experience in ambulatory transitional care or telephonic triage preferred
- Intermediate computer skills and knowledge of Microsoft Office software preferred
- Office hours must be Pacific time zone
- Ambulatory care experience in a primary care clinic, telephone triage, or telephonic nursing strongly preferred
Benefits
Comp & perks- Generous benefits package covering programs for wellness, health, security, connection, and engagement
- Company equipment and remote-work support referenced in remote work expectations