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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in ambulatory care management, including the development and implementation of patient-centered care plans, chronic disease management, and effective collaboration with healthcare teams. Proficient in conducting assessments, facilitating care transitions, and utilizing motivational interviewing techniques to support patient self-management.
Highest-signal resume keywords
Registered Nurse (RN) LicenseBachelor of Science in Nursing (BSN)Chronic Disease Management ExperienceCare Management CertificationCase Management 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-Centered Care PlansChronic Disease ManagementMotivational InterviewingCare Management ScreeningsAssessments and EvaluationsRoot-Cause AnalysisData TrackingUtilization ReviewDischarge PlanningCommunity Resource Connection
Soft Skills
CollaborationCommunicationPatient EducationBehavior Change SupportPartnership Building
Tools & Technologies
Microsoft OfficeElectronic Medical Records
Certifications & Qualifications
Basic Life Support (BLS)Care Management Certification
Industry Keywords
Ambulatory Care ManagementChronic Disease TerminologyHealthcare Team CoordinationPost-Acute ServicesProcess Improvement Initiatives
About the role
Key responsibilities & impact- Deliver comprehensive ambulatory care management services to identified patients
- Conduct care management screenings, assessments, and evaluations
- Develop, implement, maintain, and monitor individualized patient-centered care plans
- Identify patients for proactive interventions using screening criteria, medical-record review, payer models, risk scores, or referrals
- Assess medical, functional, and social conditions and connect patients with community resources
- Support patient self-management and behavior change through motivational interviewing and coaching
- Educate patients and healthcare team members about conditions, self-management, case-management processes, and referrals
- Collaborate with physicians, healthcare teams, payers, families, community providers, and other parties to coordinate timely care
- Participate in rounds and case conferences and coordinate multidisciplinary resources
- Build partnerships with hospital care management, post-acute providers, and other care managers to ensure seamless transitions
- Participate in system and regional process-improvement initiatives
- Facilitate advance care planning and patient/family care conferences
- Conduct root-cause analysis of extended post-acute stays, inappropriate utilization, and readmissions
- Track key data elements and monitor industry, regulatory, technology, and market trends affecting ambulatory and post-acute services
- Promote Intermountain Health’s mission, vision, values, and service behavior standards
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 years of hire or promotion
- 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 variation
- Proficiency in basic computer skills and Microsoft Office software
- For home or community visits: current BLS certification, current driver’s license, current auto insurance, acceptable driving record, and reliable transportation
- Care management certification preferred
- Experience in case management, utilization review, or discharge planning preferred
Benefits
Comp & perks- Benefits eligible
- Comprehensive benefits package covering programs for wellness, health, security, connection, and engagement
- Company equipment and remote-work support for applicable hybrid roles