15 days old

Care Coordinator, Behavioral Health, Adult

Umpqua Health
Roseburg, OR 97470
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This position is grant-funded for a duration of 14 months, although the grant is anticipated to end in 2022, there may be an opportunity to extend employment following the end of grant period. The Adult Behavioral Health Coordinator is a member of the Behavioral Health team for Umpqua Health Alliance (UHA) Oregon Health Plan (OHP) enrollees and Medicare members. This role forms part of the Intensive Care Coordination (ICC) program which is a collaborative, comprehensive, integrated and interdisciplinary-focused Coordinated Care Organization (CCO) program staffed with team members focused on addressing interrelated medical, social, cultural, developmental, behavioral, educational, spiritual and financial needs in order to achieve optimal health and wellness outcomes for each member in need. This position may have their assignments changed based on member population changes and departmental needs.

This position is responsible for member-focused, individualized intensive care coordination plans (ICCP) and providing 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 Adult Behavioral Health Coordinator utilizes clinical expertise in behavioral health conditions and knowledge regarding the adult system of care to provide coordination that member focused, strengths based, trauma-informed and culturally and linguistically appropriate.

  • Primarily works with adults providing care coordination and utilization review using clinical criteria set.
  • Care coordinator for the Temporary Assistance for Needy Families (TANF) pilot program responsible for connecting adult members with behavioral health needs to commensurate services and resources
  • Demonstrate an on-going understanding and current knowledge of public benefit programs, specifically Temporary Assistance for Needy Families (TANF); including awareness of social and economic conditions and their effects upon individuals
  • Command strong working knowledge of the TANF pilot program resources and workflows so as to educate and support members through the processes involved in the different service delivery systems they will encounter
  • Provide support and follow-up on project-related behaviors and outcomes, requiring liaise with partner organizations to facilitate referrals, ultimately connecting pilot program participants to behavioral health services and community resources
  • Organize, collect, track, and communicate accurate information to program manager for members engaged in pilot program, including data that pertains to project-related outcomes
  • Support program activities such as data gathering for members engaged in pilot program, preparing materials, identifying recurrent programmatic challenges, arranging meetings, and other duties as assigned.
  • Accept assignment of and maintain a caseload of members based on behavioral health assessment, DHS referral, clinic assignment, or placement in facility-based care; ensure members have access to appropriate care provider(s) who can meet their needs.
  • Develop strong working relationships with referral sources for community social services, behavioral health, healthcare, and provide referrals as needed
  • Demonstrate strong working knowledge of the current version of American Society of Addiction Medicine (ASAM) criteria, capable of providing brief screenings and/or brief evidence-based behavioral interventions to refer members to the most appropriate level of care, with awareness of prevailing treatment programs and facilities
  • Assess overall risk of member, including physical condition, behavioral issues, mental status, social support system availability, and relationship with providers.
  • 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 risk factors and service needs that may impact member outcomes
  • Acknowledge members right to choice of treatment or refusal of treatment.
  • Utilize assessment information to develop an ICCP to provide member-focused care and support
  • Assist in helping members move through the continuum of care based on clinical/medical need
  • Respond to requests for ICC screening services in a timely manner, prioritizing high risk members to facilitate prompt access to care
  • Document in appropriate electronic systems coordination notes and patient needs including barriers encountered
  • Work closely and collaborate with behavioral health treatment providers, crisis services, Developmental Disability, APD, DHS, state and county case workers, community partners, provider network, wraparound teams, and other relevant parties
  • Provide face to face, telephonic, video conference and community-based care coordination to eligible members and families
  • 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, and inpatient acute care hospitals
  • Assist in transition/discharge planning to ensure the member successfully 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
  • Coordinate with providers to ensure consideration is given to unique needs in integrated planning and that care plans are timely and effective.
  • Participate in an interdisciplinary team for integrated care plan support of complex members
  • Provide direction as appropriate to non-clinical Care Coordination staff involved with the member
  • May provide training and education to provider network on the availability of ICC services and other support services available to members
  • Maintain updated knowledge of the Oregon Administrative Rules (OAR) governing OHP.
  • Remain current on Medicaid and Medicare guidelines, the appeals and grievance process and the members rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) Oregon Health Authority (OHA) and Centers for Medicare and Medicaid Services (CMS), maintain working knowledge of Native American Oregon Health Plan Fee-For-Service program benefits
  • Knowledge of culturally-specific issues, resources and strengths of the populations served and will have knowledge of culturally-specific issues, resources and strengths of the AI AN populations.
  • Demonstrate an on-going understanding and current knowledge of benefits for Medicare and Medicaid populations.
  • Comply with organizations internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
  • Other duties as assigned.



Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.


Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.

Be a Team Player

Support and assist your team members. Be available to help, and learn from your team. Keep an open mind to feedback and earn trust of staff.


Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.


Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.

  • Working with a variety of personalities, maintaining a consistent and fair communication style.
  • Satisfying the needs of a fast paced and challenging company.

  • REQUIRED- Bachelors degree in social work, counseling, or psychology plus five (5) years experience in adult behavioral care
  • PREFERRED- Masters degree in social work, counseling, or psychology plus two (2) years experience in adult behavioral care
  • PREFERRED- Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Social Worker (LCSW), or Licensed Psychologist
  • PREFERRED- CADC II and higher
  • PREFERRED- Experience in Behavioral Health, utilization management, case management and managed care preferred.


Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds. May be exposed to member and environment conditions such as unpleasant sights, smells and contagious diseases. Job Conditions: May be required to work or attend meetings after hours. May be on call through the use of a cell phone. Position involves exposure to people with a wide variety of health problems. May be called upon to work with difficult client and crisis situations.


Posted: 2021-05-29 Expires: 2021-06-29

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Care Coordinator, Behavioral Health, Adult

Umpqua Health
Roseburg, OR 97470

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