Primary Care Case Manager

We are currently looking for a Full-Time Primary Care Case Manager to join our Ardmore Clinical Services and RN Team located at the Ardmore Health Clinic. Summary: The Case Manager provides comprehensive, patient-centered care coordination by supporting clinical workflows, managing patient panels, and ensuring timely follow-up for patients with routine and complex healthcare needs.

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.

Responsibilities

• Participates in hospital, departmental, and CNDH 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 * Plans patient care to meet set standards for quality * Provides routine patient care by utilizing and documenting the nursing process: including teaching patients and their families * 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 * Practices in accordance with and adheres to regulations such as the Nurse Practice Act, CNDH policies and procedures, and regulatory agencies * 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 * Provides safe nursing interventions ensuring that it is appropriate to patients’ needs, age and condition * Maintains and promotes professionalism and is courteous to patients, staff and visitors * Protects the confidentiality, security, and integrity of information by adhering to applicable regulatory requirements and internal policies * Regularly attends 90% of staff meetings or obtains minutes and assumes responsibility for the information given * Participates in the orientation and onboarding of new staff and supports clinical education by facilitating shadowing experiences for nursing and other clinical students * Facilitates communication via 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 * Collaborates with inpatient case management as needed to support discharge planning, care coordination, and follow-up, depending on patient needs and clinic workflows * Provides case management services for all patients, including those with complex or special healthcare needs, collaborating with internal and external providers to coordinate care and support effective transitions throughout the healthcare system * Provides direct nursing care backup as the team's needs dictate * Assists in supporting increased access to patients * 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 * Contributes to the team in a positive way that promotes professionalism and collaboration between departments * Participates in the review of monthly performance measures and work collaboratively with the care team to identify trends, challenges, and improvement opportunities * 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 * Documents patient encounters and related activities, such as observations, phone communications, direct care, and nursing interventions, in accordance with facility policies and procedures * Assumes additional responsibilities as needed while proactively identifying opportunities to improve processes and support organizational success * Participates in patient panel management activities by ensuring patient assignment information is current in the medical record and collaborating with clinic leadership on panel optimization efforts * Performs all other duties as assigned Competencies: Essential: * Ability to foster teamwork, support staff engagement, and contribute to a respectful, collaborative environment * Ability to educate and provide preventive care to healthy individuals including guidance in nutrition, common illnesses, child growth and development * Demonstrates a positive, patient-centered, solutions focused attitude * Must be proficient in the use of electronic health record keeping systems * Possess a commitment to the Chickasaw Nation mission, vision and core values Skills: Essential: * Intermediate computer skills * Intermediate skill using Microsoft Office products * Accurate typing and/or data entry skills Experience: Essential: * 2 years directly related experience Education: Essential: * Bachelor's of Nursing * Graduate from an accredited school of nursing required Essential: * Bachelor’s degree from an accredited school of nursing, or written plan to obtain within 4 years of hire * A minimum of 2 years of RN experience or 1 year of RN experience in the hospital setting plus previous experience as an LPN/RN with duties involving case management Credentials: Essential: * Pass general background check * Basic Life Support (BLS) * Must pass internal Medication Test * Unrestricted Oklahoma Registered Nurse License * Multi-State Registered Nurse Licensure within 90 days Essential: * Must maintain current BLS certification or obtain within one (1) month of hire, if not current Working Conditions: Essential: * Works in a hospital or clinic environment * Standing up to 100% of shift * Walking up to 50% of shift * Frequently bend, kneel, stoop, push, reach * Sometimes lift and or carry over 50 lbs * Sometimes assist with lifting patients * Stressful environment due to any or a combination of deadlines, pressures, multiple tasks, lines of communication, risks, speed of operations, etc.

• Potential exposure to contagious diseases * May be required to assist individuals with unmanaged emotions * Pass pre-employment drug test * Subject to traveling and working at other locations or in other environments Training *It is the responsibility of each employee to attend required training for their position or profession as determined by their line of support (LOS) or the leadership of the Chickasaw Nation.

It is the responsibility of those who supervise, manage or otherwise lead employees or teams to ensure each employee has access to and receives all required training. Mission, Vision & Core Values Mission: *To enhance the overall quality of life of the Chickasaw people. Vision: *To be a nation of successful and united people with a strong cultural identity.

Core Values: *The Chickasaw People *Cultural Identity *Servant Leadership *Selflessness *Can Do Attitude *Perseverance *Stewardship *Trust and Respect *Loyalty *Honesty and Integrity *Teamwork