About Job

We are currently hiring a THW Care Coordinator! If you are a great communicator, compassionate, enjoy a fast-paced work environment, and value being part of a team that makes a difference, you may be the right person for the position! Apply today!

Classification: NON-EXEMPT | Status & Schedule: FULL-TIME, MONDAY – FRIDAY, 8AM – 5PM

Location: Reports to the Coos Bay office location, some remote work available
Salary: $18.60 - $26.33/HOURLY | Department: CARE COORDINATION | Reports to: DIRECTOR OF CARE COORDINATION

Supervision Exercised: NON-SUPERVISORY

Classification: NON-EXEMPT

Job Purpose: Care Coordination
This position is responsible for coordinating care for members with complex needs, ensuring services are delivered in a trauma-informed, culturally and linguistically appropriate manner. This role focuses on assessing, creating, and overseeing individualized care plans for members, while working closely with interdisciplinary teams and other agencies to ensure the delivery of integrated and effective care. The Care Coordinator will also handle written care plans, perform health risk assessments (HRAs), and manage member transitions from moderate to high-risk levels, supporting members through the continuum of care.

This position may specialize in the following population groups:
aging and elderly complex medical children and families intellectual and developmental disability mental illness substance use/abuse

Qualifications, Education, & Experience

Minimum High School Diploma or GED
Current Community Health Worker Certification strongly preferred, may consider highly qualified applicant willing to obtain
Must complete continuing education to maintain THW certification in the state of Oregon
Minimum two to three years’ experience in a medical office or clinic setting
Motivational Interviewing experience required
Two to three years’ experience working with noted specialty population group strongly preferred
Bilingual preferred, qualified, certified, or willing to obtain

Essential Responsibilities: Care Coordination

Identify risk factors and service needs impacting member outcomes, recognizing transitions from low to moderate or high risk

Utilize a trauma-informed and culturally and linguistically appropriate approach to provide member-focused care, ensuring services are respectful and aligned with members' backgrounds

Assist members in navigating the continuum of care based on clinical needs, ensuring seamless transitions

Develop and implement individualized Intensive Care Coordination Plans (ICCP) for assigned members, ensuring they are member-centered and goal-focused

Interface with various agencies, including behavioral health providers, APD, DHS, and others to ensure coordinated and comprehensive care

Coordinate with healthcare providers to address unique member needs and ensure timely, effective care plans

Identify and report suspected abuse and neglect issues to mandated authorities as appropriate

Implement care plans in collaboration with members, providers, caseworkers, and other stakeholders

Respond promptly to requests for care coordination screening services and follow up on member needs

Work closely with behavioral health providers, crisis services, community partners, and interdisciplinary teams to deliver integrated care

Conduct outreach calls for members transitioning risk levels and perform annual HRAs for those with active care plans

Provide various forms of care coordination (face-to-face, telephonic, video) to ensure timely communication with members and families

Maintain and manage a caseload of members, supporting their health progress according to established policies

Perform health risk screenings to assess members' health and overall well-being, documenting findings to inform care plans

Familiarize members with available resources in Coos and Curry counties, ensuring access to the best services

Track and document member progress, responding to any triggering events requiring additional services

Develop and maintain strong relationships with members, their care teams, and community resources

Actively participate in interdisciplinary teams to support integrated care plans for complex members

Provide coaching and training to new employees on care coordination services, as needed

Provide education for network providers on care coordination services and other support options

Ensure adherence to company policies, handle confidential information securely, and maintain compliance with

regulatory requirements

Participate in quality and organizational process improvement activities as requested

Perform other duties as assigned to support organizational goals and member outcomes

Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER

Participate in quality and organizational process improvement activities when requested
Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies
and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
Advance personal knowledge base by pursuing continuing education to enhance professional competence
Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
Represent organization at meetings and conferences as applicable

Knowledge, Skills, & Abilities

Understanding of principles of health care of populations
Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical
Assistance Program (MAP) rules and regulations preferred
Knowledge of the Oregon Health Authorities Coordinated Care Organization required metrics
Understanding of basic concepts of managed care
Basic medical knowledge including ability to recognize social and medical risk factors, trauma symptoms and behaviors, and chronic disease conditions
Knowledge of medical terminology
Knowledge of electronic medical record (EMR) and/or transactional system use
Knowledge of community resources, system navigation
Knowledge of various outreach and direct services
Knowledge of motivational interviewing and non-judgmental information gathering
Knowledge of care coordination and care management
Critical attention to detail for accuracy and timeliness
High degree of initiative, judgment, discretion, and decision-making
Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of health
conditions to determine best outcomes for members
Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
Proficient in Microsoft Office Suite and Windows Operating System (OS)
Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse
Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
Excellent people skills and friendly demeanor
Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
Attention to detail and organization skills
Ability to handle stress and sensitive situations effectively while projecting a professional attitude
Ability to communicate professionally, both conversing and written
Ability to work with diverse populations and interact with people of differing personalities and backgrounds
Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
Ability to organize and work in a sensitive manner with people from other cultures
Poised; maintains composure and sense of purpose

Working Conditions:

This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.

Work Condition: hybrid work
Employee generally works within the interior of an office or remote work from home environment.
Employee may travel locally and be responsible for own transportation. Out of area travel may be required on occasion.
Hours of operations and specific staff scheduling may vary based on operational need.
The office environment is clean with a comfortable temperature and moderate noise level.

Exposed to:
Onsite: Cold/heat controls, close contact with employees and the public in office environment. Remote: Employee is
responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity
machinery, such as postage machine, fax, copier, calculator, multi-line telephone system, scanner.
May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain
or record information.
Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.

Other Information:
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of Advanced Health employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.