RN Ambulatory Care Manager

• 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 develop individualized care plans
• Connect patients with community resources and coordinate internal and external services for social determinants of health needs
• Develop, maintain, monitor, evaluate, and modify patient care plans
• Support patient self-management and behavior change through motivational interviewing and coaching
• Educate healthcare team members and patients about case management, referrals, conditions, and self-management
• Collaborate with physicians and multidisciplinary healthcare teams to ensure timely, quality care
• Participate in rounds and case conferences and consult with social work, nutrition, pharmacy, rehabilitation, and behavioral health resources
• Build partnerships with hospital care management, post-acute providers, and other care managers to support transitions and continuity of care
• Participate in system and regional process-improvement initiatives
• Facilitate advance care planning and patient/family care conferences
• Conduct root cause analyses and track metrics related to post-acute stays, utilization, and readmissions
• Analyze 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

• 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
• MVR verification
• 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
• Demonstrated experience in case management, utilization review, or discharge planning preferred
• Ability to perform the stated physical requirements, including patient transfers, lifting, walking, standing, computer use, and operating equipment
• Monday-Friday daytime availability; no weekends

Core Competencies

Demonstrates expertise in patient assessment, care planning, and chronic disease management while effectively collaborating with multidisciplinary healthcare teams. Proficient in motivational interviewing and case management practices to enhance patient self-management and care continuity.

Highest-signal resume keywords

• Registered Nurse (RN) License
• Bachelor of Science in Nursing (BSN)
• Chronic Disease Management
• Case Management Experience
• Care Management Certification

ATS Optimization Keywords

Hard Skills

• Patient Assessment
• Care Plan Development
• Motivational Interviewing
• Utilization Review
• Discharge Planning
• Basic Computer Skills
• Microsoft Office Proficiency

Soft Skills

• Collaboration
• Communication
• Patient Education

Certifications & Qualifications

• Basic Life Support (BLS) Certification
• Care Management Certification

Industry Keywords

• Chronic Disease Terminology
• Social Determinants of Health
• Post-Acute Care
• Healthcare Team Collaboration
• Process Improvement