Inchokma Prevention and Healthy Aging Case Manager

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…