Care and Outreach Specialist - HCP

The Care and Outreach Specialist works as part of a comprehensive care team, alongside nurses, social workers, and behavioral health specialists. The purpose of this team is care coordination for the organization’s most vulnerable, at-risk members. We aim for a trauma-informed and member-centric approach to coordination which takes into consideration the global health of an individual including their physical, social, mental, and dental health needs. The overall programmatic aim is to directly improve quality of care and thereby reduce avoidable hospital admissions. This position is responsible for outreach to members with a goal to support any identified unmet need of the member. This position requires critical thinking, independent judgment, as well as comfort in community, home, hospital, and healthcare settings where connecting with members may take place. Core functions of the position include addressing members’ care coordination needs, identifying appropriate resources to engage, tracking information, and providing support to members as needed. Key partners in this process are the member and relevant family/caregivers, healthcare providers, community partners, and internal staff and programs.

NOTE: The schedule is 4 ten-hour weekdays, and this position will cover Portland metro including Multnomah, Clackamas, and Washington counties.

Estimated Hiring Range

$28.23 - $34.50

Bonus Target

Bonus - SIP Target, 5% Annual

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

Essential Responsibilities

Triage and Direct Care Coordination

• Gather and review all available and relevant member information in order to identify unmet physical, behavioral, social, or medical needs.
• Address members’ barriers to care and identify potential resources while balancing cultural factors, social determinants, and member autonomy.
• Review and assess hospital admission reports, other targeted patient lists, health plan claims, pharmacy records, EHR, and other relevant information to support plan of care or needs assessment.
• Assume direct care coordination for members and provide warm handoff of members with complex medical or behavioral health needs to appropriate resources as indicated.
• Acknowledge member’s right to choose treatment or refuse treatment.
• Identify suspected abuse and neglect issues and appropriately report to mandated authorities.
• Closely partners with the member’s providers and other members of the MDT across the continuum to facilitate care that meets the individual’s personal needs, values, and preferences.
• Coach members in navigating the health care delivery system, gaining access to appropriate community resources, negotiating transitions in their health care, and determining ways to improve self-management and satisfaction with their quality of life.
• Engaging member in advance care planning conversations and determining preferences for end-of-life care. Establish effective relationships with community partners and maintain familiarity with key services and resources available to members.
• Participate in team huddles to develop, implement, and evaluate process improvement measures.
  
  

Data Collection and Compliance

• Identify opportunities for increased case finding efficiencies and effectiveness.
• Collect and/or audit data and 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.
• Complete initial and subsequent documentation pertinent to care coordination activities.
• Document all encounters in an accurate and timely manner in accordance with HIPAA laws, as well as internal 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
• Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle
  
  

Preferred

• Licensed practical nurse (LPN), certified medical assistant (CMA), certified nurse’s assistant (CNA), or other health related field
• Working 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
• Experience with MMIS, QNXT, EDIE/PreManage, SAS, EPIC, and/or other EMR database systems
  
  

Knowledge, Skills And Abilities Required

Knowledge

• Understanding of the nature of member engagement and vulnerable, at-risk populations
• Applied knowledge of the social determinants of health and the unique needs of low-income and marginalized communities
• Ability to be sympathetic to member, family, and caregiver needs and ability to work with people in various states of pain, trauma, and tragedy
• Comfort with discussion of member goals of care and end of life treatment preferences when needed
• Awareness of health system strategies to engage and improve health outcomes in this population
• Understanding of the impacts of trauma on health
• 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, EDIE/Premanage, 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 develop a concise, initial assessment to appropriately triage and prioritize daily work flow
• 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 work independently in a fast-paced, multi-faceted environment
• Ability to prioritize tasks and manage time effectively
• Demonstrated strength in the areas of critical analysis, creative problem-solving skills, and collaboration in multi-disciplinary teams
• Detail oriented, accurate record keeping
• Effective motivational interviewing, health care teaching, and coaching principles
• Adept at mobile communication and production tools
• Ability to adhere to organizational standards, policies, and procedures
• 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
• Ability to operate a motorized vehicle in all kinds of weather conditions
  
  

Working Conditions

Work Environment(s): ☒ 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: Requires travel outside of the workplace at least weekly; the employee’s personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy.

Schedule: This position may occasionally require more than 8 hours per day.

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 (including THC/Marijuana). CareOregon is a federal contractor and must comply with all federal laws.

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 (including THC/Marijuana). CareOregon is a federal contractor and must comply with all federal laws.

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. Housecall Providers 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

Housecall Providers 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.