Intensive Care Coordinator – Masters Degree

Are you drawn to complex work that requires a blend of mind, heart and flexibility? Please consider CareOregon. We’ve been strengthening communities since 1994 by making health care work for everyone. As a nonprofit health plan largely focused on Oregon Health Plan clients, we stand firmly in support of the underserved.

We carry out this commitment in various regions of our majestic state—including Columbia County along the Columbia River, and Clatsop and Tillamook counties on Oregon’s north coast. This rural area--dotted with towns such as Seaside, home to our office--is an interplay of tourism, invigorating ocean air, a cooler climate, and the Clatsop State Forest’s trails and lakes. Please consider joining us here at Columbia Pacific CCO, our Coordinated Care Organization dedicated to our members’ physical, emotional and oral health. We look forward to your application!

*This position can be performed in Tillamook, Seaside, or Portland*

General Statement of Duties

The Intensive Care Coordinator (ICC) is responsible for developing and implementing member-centric, individualized care plans and providing telephonic and community-based care coordination for members with high health care needs, including members with complex behavioral concerns, severe and persistent mental illness, substance use disorders, and/or receiving facility based, in-home or community-based psychiatric services. The ICC utilizes clinical expertise in behavioral health conditions and knowledge regarding the adult and children’s system of care to provide coordination that is member driven, strengths based, and culturally and linguistically appropriate. The ICC acts as the primary care coordination liaison for providers working with members involved in, on waitlists for, or who may qualify for, Wraparound or Choice Model Services.

Intensive care coordination is provided throughout programs and levels of care for the highest need, most vulnerable adults and children, as they transition in and out of intensive community and

facility based programming including but not limited to:

§ Psychiatric acute care and subacute settings

§ Oregon State Hospital/Secure Child Inpatient/Secure Adolescent Inpatient, Forensic

§ Psychiatric Residential Treatment Services

§ Substance Use Detox and Residential Programs

§ Children and youth who are:

o Engaged in mental health services that have two or more placement disruptions due to emotional and/or behavioral precipitators in less than one year

o Placed in a correctional facility solely for the purpose of stabilizing a mental health condition

o Placed out of the CCO catchment area in Behavior Rehabilitation Services programs under the jurisdiction of child welfare

o At risk of losing home or school placement due to emotional and/or behavioral precipitators

Essential Position Functions

Assessment and Care Planning

§ Assess for and identify 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 care and support.

§ Assist in helping members move through the continuum of care based on clinical/medical need.

§ 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 care plans are timely and effective.

§ Identify suspected abuse and neglect issues and appropriately report to mandated authorities.

§ Implement care coordination plan in collaboration with member, providers, case workers and other relevant parties.

§ Work closely and collaborate with behavioral health treatment providers, crisis services, Developmental Disability, APD, DHS, etc.

Intensive Care Coordination

§ Provide telephonic and community-based care coordination to eligible members and families.

§ Assist members and families access the care and services they need without barriers.

§ Provide support and coordination for members receiving treatment in the higher levels of behavioral health care such as psychiatric residential treatment, intensive community based or psychiatric day treatment.

§ Ensure treatment recommendations are understood by the member and provider, and assist members through transitions to the next level of care or treatment provider.

§ Facilitate communication between members, their support systems other community-based partners and clinical care providers and ensure care plans are shared, as appropriate.

§ Accept assignment of and maintain a caseload of members.

§ Effectively coordinate an interdisciplinary team for integrated care plan support of complex members.

§ May participate in monthly state hospital IDT meetings as well as discharge planning meetings.

§ Participate in CCO/APD IDT meetings to coordinate care services for OHP members in long term care services.

§ Collaborate with community providers, state and county case workers, community partners, vendors, agencies, Choice contractors, wraparound teams, and other relevant parties

§ Provide direction as appropriate to non-clinical Care Coordination staff involved with the member

Transition Assistance

§ Assist in transition/discharge planning for members discharging from acute care settings or those who are transitioning from long term care, the Oregon State Hospital or other residential facilities to ensure a smooth transition back to community-based supports.

§ Ensure discharge/transition plans are evaluated holistically from physical and behavioral health perspectives

§ Ensure members on the state hospital Ready to Transition (RTT) list are prioritized for referral into appropriate transition setting through collaboration with and community partners including the CHOICE ENCC

§ May compile and distribute referral packets to residential and foster care facilities as needed

§ Coordinate care for members residing outside of service area as required in contract

Compliance

§ Maintain unit compliance with Coordinated Care Organization requirements

§ Maintain tracking data for program evaluation and reporting purposes

§ Maintain timely and accurate documentation about each member per program policies and procedures

§ 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 unit compliance with the Model of Care requirements if applicable

Essential Department and Organizational Functions

§ Forward relevant information of members requiring special consideration of benefits to Medical Management Review RNs or to affiliated CareOregon programs

§ Serve as a resource to the organization on mental health and alcohol and other drug topics and issues

§ May provide coaching and training on specific job responsibilities to new employees in this role

§ Report to work as scheduled and follow attendance policies

§ Participate in quality and organizational process improvement activities and teams when requested

§ Participate in work-related continuing education when offered or directed

§ Perform other duties and projects as assigned

Knowledge, Skills, and Abilities Required

§ Knowledge of current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for mental health and substance dependence/abuse diagnoses, ASAM (American Society of Addiction Medicine) criteria for alcohol and/or drug dependence treatment and Mental health.

§ Knowledge of best practices and treatment modalities

§ Knowledge ofco-morbidities that indicate potential for psychiatric de-compensation and/or relapse

§ Knowledge of side effects of psychotropic medications that may impact health status and adherence with treatment recommendations and behavioral health integration in primary care settings

§ Knowledge of the Oregon Health Plan benefit package, eligibility categories, and Oregon Medical Assistance Program (MAP) rules and regulations

§ Knowledge of Medicare parts A and B benefit packages and the Centers for Medicare and Medicaid Services (CMS) rules and regulations and community resources

§ Knowledge of community resources

§ Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of behavioral health conditions to link members with appropriate providers

§ Ability to meet department standards for competency in the use of motivational interviewing within 12 months of hire, collaborate with members, providers, and community partners to develop plans to address complex care needs and monitor and evaluate a plan of care for optimal outcomes

§ Ability to work in an environment with diverse individuals and groups

§ Ability to establish collaborative relationships and effectively lead a multidisciplinary team

§ Ability to manage multiple tasks and to remain flexible in a dynamic work environment and work autonomously and effectively set priorities

§ Ability to provide excellent customer service and verbal and written communication

§ Basic word processing skills

Education and/or Experience

Required:

§ Master’s degree in social work, counseling or other behavioral health field

§ Minimum 2 years’ experience in mental health and/or drug and alcohol treatment for the population being served

§ Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle

Preferred:

§ 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 the Oregon Health Plan (OHP) (Medicaid) and the Centers for Medicare and Medicaid Services (CMS) (Medicare) benefits

§ Related experience in the use of Motivational Interviewing (MI)

§ Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), or equivalent

§ Certification as CCM (Certified Case Manager) and/or Certified Alcohol Drug Counselor II or III (CADC II or III)

Working Conditions

§ Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

Inside/office Clinics/health facilities Member homes

• Other_________________________________________

§ Travel: This position requires frequent travel outside of the workplace, in which the employee’s personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy.

§ Equipment: General office equipment

§ Hazards: OSHA Category I - Assigned tasks may involve exposure to communicable diseases, blood, body fluids or tissues.

§ If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check 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.

Apply Now:

https://career4.successfactors.com/career?career%5fns=job%5flisting&company=C0007187026P&navBarLevel=JOB%5fSEARCH&rcm%5fsite%5flocale=en%5fUS&career_job_req_id=16073&selected_lang=en_US&jobAlertController_jobAlertId=&jobAlertController_jobAlertName=&_s.crb=mE1cr%2fHSib7ZjLBTe5xF3dubFyjxFSI9EiEJtkNxC9U%3d

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Education:

• Master's (Preferred)

Experience:

• mental health or drug and alcohol treatment: 2 years (Preferred)

License/Certification:

• Licensed Clinical Social Worker (Preferred)
• Licensed Professional Counselor (Preferred)

Company's website:

• https://www.careoregon.org/

Company's Facebook page:

• https://www.facebook.com/CareOregon