FREE ACCESS
5,000–10,000 jobs/day
See all jobs on Scoutfield
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in patient care coordination, including conducting assessments, managing care plans, and maintaining compliance with HIPAA regulations. Proficient in utilizing electronic health records (EHR/EMR) and fostering effective communication among interdisciplinary teams and patients.
Highest-signal resume keywords
California Licensed Vocational Nurse (LVN)Patient Care CoordinationExperience with EHR/EMR SystemsGeriatric Care ExperienceStrong Interpersonal and Communication Skills
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 AssessmentsCare CoordinationDocumentation of Clinical InterventionsMedication ManagementKnowledge of Value-Based Care
Soft Skills
Strong Organizational SkillsTime ManagementProblem-Solving SkillsAdaptabilityInitiative
Tools & Technologies
Electronic Health Records (EHR/EMR)Care Management SystemsMicrosoft OutlookMicrosoft WordMicrosoft Excel
Certifications & Qualifications
Current CPR CertificationProof of Full COVID Vaccination
Industry Keywords
Medicare PopulationsAssisted Living FacilitiesLong-Term CareInterdisciplinary Clinical TeamPatient Confidentiality
About the role
Key responsibilities & impact- Manage an assigned panel of Medicare beneficiaries
- Serve as the operational link among patients residing in assisted living facilities, their families and caregivers, providers, facility staff, and the interdisciplinary clinical team
- Schedule and coordinate regular provider visits for assigned patients
- Conduct structured patient outreach and assessments by telephone and in assisted living communities
- Collect clinical, functional, and psychosocial information
- Provide patient and family/caregiver education and support related to diagnoses, treatment plans, services, and self-management
- Develop and maintain effective relationships with patients, families, caregivers, and facility staff
- Assist clinical team members with obtaining medical records, laboratory results, imaging reports, and other relevant patient information
- Identify and address changes in condition, care gaps, medication concerns, unmet social needs, barriers to care, and opportunities to reduce avoidable emergency department visits and hospitalizations
- Support implementation and follow-up of patient care plans and service needs
- Communicate and track identified actions through resolution or escalation
- Contribute patient and care coordination insights to weekly interdisciplinary team discussions
- Maintain accurate, timely, and complete documentation of assessments, interventions, patient responses, communications, and follow-up activities
- Participate in quality assessment and performance improvement initiatives
- Maintain patient confidentiality and comply with HIPAA and applicable requirements
- Perform other duties as assigned
Requirements
What you’ll need- Must reside in California
- Current California Licensed Vocational Nurse (LVN) license in good standing
- Current CPR certification as required by organizational policy
- One (1) to three (3) years of nursing experience
- Strongly preferred: Experience working with older adults in assisted living facilities (ALFs), long-term care, skilled nursing, or other senior care settings
- Geriatric and/or primary care experience strongly preferred
- Experience with long-term care or assisted living EHR/EMR systems preferred
- Knowledge of value-based care, care coordination, and/or Medicare populations preferred
- Ability to conduct independent visits to assisted living facilities throughout an assigned region; travel is required
- Reliable transportation required for conducting patient visits
- Ability to coordinate services across providers, facilities, patients, caregivers, and external partners and track identified needs through resolution or appropriate escalation
- Strong organizational and time-management skills with the ability to prioritize competing demands and manage multiple tasks efficiently
- Ability to document clinical assessments, outreach, interventions, patient responses, communications, and follow-up activities accurately and within required timeframes
- Strong interpersonal and communication skills, including the ability to effectively communicate with older adults, individuals with cognitive impairment, family members, caregivers, facility staff, and healthcare providers
- Demonstrates initiative, sound judgment, adaptability, resourcefulness, and effective problem-solving skills
- Ability to work independently while also collaborating effectively within an interdisciplinary clinical team
- Comfortable working in a developing, fast-paced program and adapting to evolving workflows, technology, and operational requirements
- Proficiency with electronic health records (EHR/EMR), care management systems, Microsoft Outlook, Word, Excel, virtual meeting platforms, and other clinical or administrative software
- Strong written communication and documentation skills, including the ability to prepare clear, accurate, concise, and professional clinical notes and correspondence
- Must comply with HIPAA, organizational policies, documentation standards, and applicable federal and state requirements
- Proof of full COVID vaccination required as a condition of employment, subject to legally recognized accommodations
Benefits
Comp & perks- Professional development
- COVID vaccination requirement subject to legally recognized accommodations