Health System Care Coordinator

The Health System Care Coordinator (HSCC) acts as entry point to Health Share’s Regional Care Teams, as well as provides care coordination. Under minimal supervision this position provides intake functions, working in concert with physical and behavioral health providers, outside community partners/agencies and other external and internal partners to assist in plan navigation, timely access to care, and other care coordination activities in assuring, maintaining continuity of care and optimizing member well-being. The HCC II role will involve managing a higher, more varied caseload, and may handle cases that necessitate an interdisciplinary team (IDT) or interdisciplinary care team (ICT) approach, also collaborating with community partners or internal resources. The HCC II may work alongside a clinical care coordinator (RNCC, ICC, HRS etc.).

This is a hybrid position with the expectation to be in office or system partner offices 1-2x per week.

Estimated Hiring Range

$39.93 - $48.81

Essential Responsibilities

Clinical Assessment

• Assess overall risk of member, including physical condition, behavioral issues, mental status, social support system availability, and relationship with providers.
• Utilize assessment information to develop individualized plans of care for assigned members.
• Coordinate with providers to ensure consideration is given to unique needs in integrated planning and that care plans are timely and effective.
• Practice using a trauma-informed and client-centered approach with members by respecting their autonomy, exploring any ambivalence, meeting resistance with acceptance and following their lead in developing care plans.
• Identify suspected abuse and neglect issues and appropriately report to mandated authorities.
• Acknowledge member’s right-to-choice of treatment or refusal of treatment.
• Provide culturally and linguistically appropriate ICM services to members identified as Aged, Blind, and Disabled, members with special health needs (complex, high utilization, multiple comorbidities, and/or serious behavioral health issues) and those in Long Term Care services under the State’s 1915(i) State Plan Amendment.
• May provide individualized plans of care for high-risk COA Plus members and review those plans with ICT team.
  
  

Care Coordination

• Provide telephonic-based physical and behavioral health care coordination to eligible members and families.
• Maintain a caseload of members with ongoing physical and behavioral health care coordination needs.
• Assist members and families to access the care and services they need without barriers.
• Facilitate communication between members, their support systems, other community-based partners, clinical care providers and other Health Share departments, and ensure care plans are shared, as appropriate.
• Effectively coordinate with an interdisciplinary team for integrated care plan support of complex members and participate in a variety of multidisciplinary care team meetings; coordination includes internal care team and frequently includes external members such as community providers, state and county case workers, community partners, vendors, agencies, contractors, other Health Share departments and other relevant parties (Health Care Coordinator /American Indian Alaska Native will also collaborate with Tribal health leaders).
• Provide support as appropriate to clinical Care Coordination staff involved with the member.
• Assist members in establishing/engaging with providers.
• Refer members in care coordination to different agencies for community supports.
• Coordinate care for members residing outside of service area as required in contract.
• Coordinate care for members discharging from the state hospital.
• Coordinate care for members involved with county ICC programs or members that are transitioning out of ICC back to Health Share Care Coordination.
• Assist in transition/discharge planning for members discharging from acute care settings or those who are transitioning from long term care, or other residential facilities to ensure a smooth transition back to community-based supports as deemed appropriate by clinical supervisor.
• Take independent actions to address members’ identified needs including, but not limited to: scheduling provider appointments, arranging for transportation, arranging for an interpreter when needed, confirming authorization/referral is in place, assisting with Health Related Services Flex requests, verifying needed services are provided, referring to community resources and locating members.
• Develop working partnerships with community health care providers regarding member needs and care plans.
• Complete specialized training to deepen their ability to offer care coordination to a broader population of vulnerable and/or complex member needs.
  
  

Assessment and Care Planning

• Assess for and identify physical and behavioral health care coordination needs.
• Identify risk factors and service needs that may impact member outcomes and address appropriately.
• Utilize a trauma-informed approach to provide member-centric physical and behavioral health care and support.
• Assist in helping members move through the continuum of care based on clinical/medical/behavioral health needs.
• Use motivational interviewing to coach members toward improved physical and behavioral health care behaviors and self-management.
• Utilize assessment information to develop individualized care plans for assigned members.
• Coordinate with providers to ensure consideration is given to unique needs in integrated planning and that physical and behavioral health care plans are timely and effective.
• Implement physical and behavioral health care coordination plan in collaboration with member, providers, case workers and other relevant parties.
  
  

Compliance and Administration

• Complete initial and subsequent documentation and processes in care coordination activities and when supporting clinical care coordinators in creation of plans of care, according to the care coordination timeline of activities.
• Maintain working knowledge of COA and OHP benefits, including Addictions and Mental health benefits.
• Report member complaints to Appeals and Grievance team for investigation and follow-up, per protocol.
• Assist Quality Assurance (QA) staff in identifying behavioral health providers with practice patterns which are not in conformity to best practice standards.
• Maintain compliance with the Model of Care requirements if applicable.
• Participate in quality and organizational process improvement activities and teams when requested.
• Participate in work-related continuing education when offered or directed.
• Support onboarding of new HCC’s.
• Participate in work groups to discuss workflow decisions and help inform policies/procedures.
• Implement physical and behavioral health care coordination plan in collaboration with the patient’s care team, including patient, family, caregiver, internal team members, as well as external providers, case workers and other relevant parties.
• Attend system partner and plan partner meetings to identify opportunities for increased care coordination.
  
  

Required

Education and/or Experience

• Minimum 5 years’ experience working in a healthcare setting, outpatient primary care clinic, hospital, or health insurance plan
• Master's Degree in Social Work or Counseling
  
  

Preferred

• Preference may be given for current Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), or Licensed Marriage and Family Therapist (LMFT)
• Experience with a similar population in health plan case management/care coordination or behavioral health integration in a person-centered primary care home
• Experience administering work relating to the Oregon Health Plan (OHP) (Medicaid) and the Centers for Medicare and Medicaid Services (CMS) (Medicare) benefits
• Experience in the use of Motivational Interviewing (MI), certification as CCM (Certified Case Manager) and certification as Certified Alcohol Drug Counselor II or III (CADC II or III)
  
  

Knowledge, Skills And Abilities Required

Knowledge

• Advanced Knowledge of basic healthcare language, including medical and/or behavioral health
• Advanced Knowledge of community resources
• Demonstrates advanced knowledge of barriers to care such as language, cultural factors, transportation, ability to self-manage and psychosocial issues and bring those to the attention of the care team.
• Advanced Knowledge of culturally specific issues, resources and strengths of the AI AN populations for HCC positions focused on these populations
• Advanced Knowledge of Oregon Health Plan (OHP) benefit package and OHA rules and regulations
• Knowledge of Medicare parts A and B benefit packages and the Centers for Medicare and Medicaid Services (CMS) rules and regulations
  
  

Skills And Abilities

• Advanced ability to read, write, verbally communicate effectively and facilitate group discussion or case review
• Excellent listening, interpersonal and customer service skills
• Motivational interviewing, health care teaching, and coaching skills or ability to learn
• Excellent organizational skills, plus ability to manage multiple tasks and timelines in a high stress environment
• Advanced organizational skills and ability to work independently, when needed, and to use sound judgment
• Advanced ability to establish and maintain effective, collaborative relationships with colleagues, providers, community agencies and OHA staff
• Advanced computer application skills, including MS Windows, Word, Excel and Outlook
• 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, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day
  
  

Working Conditions

Primary Work Environment

☒ Indoor/Office ☒ Member Facing ☐ Patient Facing ☐ Facilities/Security

Other Work Environment(s)

☒ Indoor/Office ☐ Member Facing ☐ Patient Facing ☐ Facilities/Security ☐ Outdoor Exposure

Hazards: General office hazards, which most commonly include potential physical and ergonomic hazards, such as falls, cuts, repetitive strains, accidents, etc.

Equipment: General office equipment

Travel: This position 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.

Work Location: Hybrid-Office 1-2 Days/Week

Current Health Share Employees: Please use the internal Workday site to submit an application for this job.

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. Health Share offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

Health Share is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.