Inchokma Prevention and Healthy Aging Case Manager - 30898

Inchokma Prevention and Healthy Aging Case Manager - 30898

We are currently looking for a Full Time Inchokma Prevention and Healthy Aging Case Manager to join our Population Health Team team located at the Chickasaw Nation Medical Center working 8:00AM-5:00PM - Mo Tu We Th Fr.

The Inchokma Prevention and Healthy Aging Case Manager provides comprehensive education and care coordination to support patients in understanding and managing their condition across inpatient, outpatient, and community settings. RN Case Managers collaborate closely with providers, multidisciplinary teams, and external partners to support safe transitions of care, optimize quality outcomes, and enhance access to services. Assist in the general oversight of all CNDH Inchokma Prevention and Healthy Aging clinic and Prevention Lung Cancer Screening (PLCS) program in meeting program goals, objectives, and reporting requirements. Responsible for practicing in accordance with and adhering to regulations such as the Nurse Practice Act, CNDH policies and procedures, and regulatory agencies.

Responsibilities:

• Coordinates all clinical aspects of the Prevention Lung Cancer Screening (PLCS) Navigator
• Collaborates with administrative and clinical leadership to support implementation, oversight, and continuous improvement of the PLCS program
• Develops, implements, and refines workflows that support patient identification, eligibility determination, screening, diagnostic evaluation, treatment referral, and annual follow-up screening
• Coordinates referral pathways among primary care and CNDH Imaging
• Assists with the development of operational policies, procedures, and clinical workflows related to lung cancer screening services
• Identifies patients eligible for lung cancer screening utilizing established screening criteria and evidence-based guidelines
• Conducts patient outreach and education regarding the benefits, risks, and limitations of lung cancer screening
• Facilitates scheduling and completion of shared decision-making visits and low-dose CT screening examinations
• Coordinates follow-up diagnostic testing, specialty referrals, and treatment services as indicated
• Maintains ongoing communication with patients to reduce barriers to care and improve adherence to recommended screening and follow-up plans
• Maintains a patient recall system to support annual lung cancer screening participation
• Identifies patients who use commercial tobacco products
• Provides education regarding tobacco-related health risks and available cessation resources
• Facilitates referrals to the Oklahoma Tobacco Helpline and other evidence-based tobacco cessation programs
• Tracks tobacco cessation referrals and outcomes as required
• Collaborates closely with CNDH Imaging Program Navigator and CNDH Public Health Epidemiology to ensure data collection, analysis and reporting requirements are prepared and submitted
• Maintains a patient tracking system for eligible patients, referrals, completed screenings, diagnostic testing, treatment referrals, and annual follow-up screenings
• Ensures accurate documentation within the electronic health record and other approved tracking systems
• Collects, analyzes, and reports deidentified program data to funding agencies and stakeholders
• Monitors program performance indicators including shared decision-making visits completed; low-dose CT scans completed; Lung-RADS category distribution; tobacco cessation referrals; follow-up completion rates; and other required grant or organizational measures
• Supports quality improvement initiatives through data review, outcome monitoring, and performance improvement activities
• Serves as the main contact for all grant reporting
• Assists with grant applications, recurring funding requests, mid-year report and annual report
• Shares responsibility for monitoring grant timelines associated with statistical reporting
• Assists with analysis of statistical reporting to assist in identifying health needs of patient population
• Attends meetings about grants administered by CNDH
• Assists with preparation of reports including recommendations to be submitted to clinic leadership
• Assists with development and dissemination of patient and provider education materials related to patient visit, lung cancer screening and/or tobacco cessation
• Participates in community education, outreach events, and awareness campaigns designed to increase screening participation
• Serves as a resource to healthcare providers regarding lung cancer screening guidelines and best practices
• Participates in the Oklahoma Lung Cancer Roundtable and Oklahoma Lung Navigator Network
• Attends required training, conferences, webinars, and meetings
• Shares implementation experiences, best practices, lessons learned, and challenges to support statewide lung cancer screening improvement efforts
• Coordinates the plan of education and curricula development to meet priority patient education needs
• Shares responsibility for conducting and assessing educational needs and social drivers of health as well as instructing patients about early detection, prevention, and self-management for their disease and disease process
• Provides programs in a manner that facilitates efficiency of offering maximum client access, including satellite clinics, and positive educational impact
• Provides input for teaching programs, materials, schedules and evaluation mechanisms to benefit patients and family care, awareness, and enhanced general health and well-being
• Facilitates care coordination for IPHAC patients and follow-up when appointments are missed and ensures that new appointments are made and kept
• Maintains knowledge of existing and potential educational and professional resources, to provide learning opportunities for IPHAC patients, through continuing education, workshops and training materials
• Participates in hospital, departmental, CNDH and grant performance improvement activities to measure, assess and improve the quality of care delivered to patients
• Participates in pre-visit planning by reviewing upcoming schedules and care gap data to support timely completion of screenings and tests, including assisting with preparatory activities such as requesting records or initiating orders as appropriate, in collaboration with providers
• Provides clinical and operational support for patient care coordination and clinical workflows, including but not limited to triage processes, medication management support, referral coordination, and follow-up care, in accordance with organizational policies and procedures
• Provides age, population and culturally appropriate, holistic patient care based upon nursing department standards, policies and procedures
• Recognizes and anticipates common changes in the physical, biopsychosocial and health needs of patients experiencing urgent, emergent or non-emergent conditions
• Collaborates with the providers to provide patient and/or family education designed to meet the age specific needs of the patient population served
• Regularly attends 90% of staff meetings or obtains minutes and assumes responsibility for the information given
• Facilitates communication via electronic health record or telephone between the patient and the medical staff
• Exhibits prompt arrival to duty station as well as follows employee code book for time and attendance
• Assists with management duties of the clinic as delegated by the clinic manager and/or assistant manager in their absence, to include supervision of agency and contract staff
• Functions as a member of the interdisciplinary healthcare team, leading coordinated collaboration with multidisciplinary specialties and integrated services to deliver comprehensive, patient- and family-centered care
• Provides first class customer service to both internal and external customers and responds to inquiries, compliments, and/or complaints with professionalism, courtesy, and efficiency
• Completes all training and development requirements and participates in continuing education opportunities
• Works in a collaborative and supportive manner to support the productivity and safety of the work area, team members and customers of all types - Maintains a clean, organized work area and ensures a safe environment - Maintains and promotes professionalism - Punctual and consistent in meeting start time, work schedule, attendance and other assigned work time metrics - Adheres to Chickasaw Nation dress code standards
• Maintains knowledge of and follows all rules, regulations, policies and guidelines for assigned area
• Performs all other duties as assigned

Competencies:

• Ability to collaborate with and or coordinate efforts of others (e.g. cross-functional teams)
• Ability to determine appropriate course of action in complex situations
• Ability to prioritize, plan, develop, organize, and coordinate work involving diverse demands, short deadlines
• Able to follow instructions, both written and oral
• Able to adhere to all scheduling and attendance requirements
• Honesty, truthfulness, reliability, accountability
• Able to read, understand, apply, and retain knowledge of Chickasaw Nation, departmental, divisional and all other rules, regulations, policies, procedures and guidelines
• Able to verbally communicate in a professional and positive manner with other team members, departments, guests and management

Skills:

• Intermediate computer skills
• Medication administration
• Intermediate skill using Microsoft Office products
• Accurate typing and/