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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 patient-centered care planning, chronic disease management, and collaboration with healthcare teams. Proficient in motivational interviewing, data tracking, and understanding social determinants of health.
Highest-signal resume keywords
Registered Nurse (RN) LicenseBachelor of Science in Nursing (BSN)Clinical Nursing Experience in Chronic Disease ManagementCare Management CertificationExperience in Case Management
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 InterviewingRoot Cause AnalysisData Tracking and Metrics Monitoring
Soft Skills
CollaborationPatient EducationBehavior Change Support
Tools & Technologies
Microsoft OfficeElectronic Medical Records
Certifications & Qualifications
Basic Life Support (BLS) CertificationCare Management Certification
Industry Keywords
Ambulatory Care ManagementChronic Disease TerminologyUtilization ReviewDischarge PlanningSocial Determinants of Health
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 patient-centered care plans
- Identify patients for proactive interventions using screening criteria, medical record review, payor models, medical risk scores, or referrals
- Assess patients’ medical, functional, and social conditions and connect them 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/caregivers, community providers, and other parties
- Coordinate internal and external services for social determinants of health and community care
- Facilitate advanced 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 metrics and monitor industry, regulatory, technology, and market trends
- Participate in rounds, case conferences, system initiatives, and regional transitions-of-care improvement efforts
- Travel throughout the service area from Santaquin to Park City
Requirements
What you’ll need- Current Registered Nurse (RN) license in state of practice
- Bachelor of Science in Nursing (BSN) from an accredited institution; RNs hired or promoted into this role must obtain a BSN within four years
- 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
- Current BLS certification for home or community visits
- Current driver’s license, current auto insurance, acceptable driving record, and reliable transportation for home or community visits
- 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
- BLS certification requirement support implied for caregivers conducting home or community visits