CareOregon Hiring for Care and Outreach Specialist – PHP at Portland, OR  Full Time

Job Summary

The Care and Outreach Specialist work alongside a comprehensive care team that includes nurses, social workers, health care coordinators, and behavioral health specialists. This position requires critical thinking and independent judgment. The purpose of this role is to provide health system navigation, short term care coordination, and connection to community resources for the organization’s most vulnerable, at-risk members.

The Care and Outreach Specialist is responsible for member outreach and follow-up related to various organizational initiatives. This role will help identify and support unmet member needs identified through proactive outreach to targeted populations, health risk screenings, change in health status, and will assist in addressing gaps in care.

Essential Responsibilities

Outreach and Healthcare System Navigation

• Receive completed health risk assessment and/or screening information and review all available and relevant member information to identify unmet physical, behavioral, social, cognitive, or medical needs.
• Proactive member outreach to identify and assess for care coordination needs.
• Provide short term care planning to manage identified needs.
• Determine and address navigation, care coordination and/or resource needs while balancing cultural factors, social determinants, and member autonomy.
• Coordinate referrals as applicable.
• Address members’ navigation needs and identify potential resources.
• Assume direct healthcare navigation for members and provide warm handoff of members with complex medical or behavioral health needs to appropriate care coordination staff.
• As able to identify suspected abuse and neglect issues and appropriately report to mandated authorities.
• Collaborate and facilitate services that meets the member’s personal needs, values and preferences with physical health, dental health, behavioral health treatment providers (i.e., crisis services, Department of Developmental Disability, APD, Department of Human Services (DHS), etc.).
• Coach members in navigating the health care delivery system, gaining access to appropriate community resources, and determining ways to improve self-management and satisfaction with their quality of life.
• Input information into the centralized care coordination platform and document all related activities.
• Provide cross-training on specific job responsibilities.

Compliance

• Maintain compliance with all contractual and regulatory requirements.
• Maintain timely and accurate documentation about each member per program policies and procedures.
• Maintain working knowledge of COA and OHP benefits including physical health and behavioral health.
• Maintain compliance with the Model of Care requirements if applicable.
• Review and/or audit health risk assessment and/or screening information to inform or evaluate departmental, organizational metrics and regulatory requirements.
• Contribute to continuous process improvement through participation in team huddles, training, departmental, team, and organizational meetings.
• Organize, facilitate, and track member care planning and interdisciplinary care team completion.
• Assist in proactive case finding; provide documentation and facilitation of care coordination in relation to a member’s change in health status.
• Maintain timely and accurate documentation about each member per program policies and procedures.

Organizational Responsibilities

• Perform work in alignment with the organization’s mission, vision and values.
• Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization’s strategic goals.
• Adhere to the organization’s policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• Minimum 3 years of directly related experience working with vulnerable populations in a healthcare setting, social service agency, outpatient primary care clinic, hospital, or health insurance plan
• Experience should include working with consumers of Medicaid and Medicare healthcare services and an understanding of the psychosocial and medical barriers encountered by this population

Preferred

• Work directly or telephonically with a population similar to that found on the Oregon Health Plan and/or working with a community-based mental health or addictions population
• Database Experience: MMIS, QNXT, Collective, EPIC, and/or other EMR systems

Knowledge, Skills and Abilities Required

Knowledge

• Understanding of the nature of member engagement and the awareness of health system strategies to improve health outcomes with the vulnerable, at-risk population, including impacts of trauma on health
• Applied knowledge of the social determinants of health and the unique needs of low-income and marginalized communities
• Intermediate understanding of medical terminology and general familiarity with common medical conditions as well as implications of unstable disease processes
• Familiarity with standard office technology including Microsoft office software or comfort and experience with learning similar systems
• Familiarity with health plan claims systems, electronic health record applications and other sources of clinical information or comfort and experience with learning new systems

Skills and Abilities

• Excellent organizational skills and ability to manage multiple tasks with emphasis on case and care management priorities
• Ability to synthesize multiple aspects of a members medical or social situations especially those that pose a risk to member’s safety or wellness and increase likelihood of rehospitalization
• Ability to effectively gather relevant health and social information directly from the member or other sources
• Ability to maintain strict confidentiality, observing all HIPAA rules
• Ability to maintain professional boundaries and effective working relationships with internal and community service staff, members, and providers
• Ability to develop a concise, initial assessment of appropriately triage and prioritize daily workflow
• Willingness to seek support from clinical staff and/or supervisors in the event of complex situations
• Ability to work independently and use sound judgment
• Excellent interpersonal and customer service skills
• Ability to prioritize tasks and manage time effectively
• Ability to do critical analysis, creative problem-solving skills, and collaboration in multi-disciplinary teams
• Ability to participate in work-related continuing education when offered, requested, or directed
• Effective motivational interviewing, health care teaching, and coaching principles
• Adept at mobile communication and production tools

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to pinch small objects for at least 3-6 hours/day

• Ability to stand, walk, sit, bend, lift, carry, push, pull, crouch, crawl, reach and climb stairs for at least 1-3 hours/day

Working Conditions

Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical, ergonomic, and biological hazards.

Equipment: General office equipment and/or mobile technology

Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check, immunization review, and drug screen. CareOregon is a federal contractor and must comply with all federal laws.

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.