- 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, payor models, risk scores, or referrals
- Connect patients with community resources and coordinate internal and external services for social determinants of health needs
- 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 care managers
- Participate in rounds or case conferences and facilitate multidisciplinary, team-based care
- Build partnerships supporting seamless transitions and continuity of care
- Participate in initiatives to improve transitions of care and avoid duplicative services
- Facilitate advance care planning and patient/family care conferences
- Conduct root cause analyses and track metrics related to extended stays, utilization, readmissions, and other trends
- 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 a 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 variations
- 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
- Ability to perform the stated physical requirements, including patient transfers, lifting, ambulation assistance, equipment handling, computer use, and prolonged standing or driving as applicable
Core Competencies
Demonstrates expertise in delivering patient-centered care management, including conducting assessments, developing care plans, and coordinating services. Proficient in chronic disease management and effective communication with healthcare teams and patients.
Highest-signal resume keywords
- Registered Nurse (RN) License
- Bachelor of Science in Nursing (BSN)
- Chronic Disease Management
- Care Management Certification
- Case Management Experience
ATS Optimization Keywords
Hard Skills
- Patient-Centered Care Plans
- Care Management Screenings
- Motivational Interviewing
- Root Cause Analysis
- Utilization Review
- Discharge Planning
- Basic Computer Skills
- Microsoft Office Proficiency
Soft Skills
- Collaboration
- Communication
- Patient Education
- Behavior Change Support
Certifications & Qualifications
- Basic Life Support (BLS) Certification
Industry Keywords
- Chronic Disease Terminology
- Social Determinants of Health
- Transitions of Care
- Multidisciplinary Team-Based Care