Clinical Coordination Specialist

Cascadia Health•Portland, OR

3d•Onsite

About The Position

The Clinical Coordination Specialist, part of Cascadia Health’s Integrated Team Based Care program, facilitates comprehensive care for clients across mental health, addiction medicine, physical healthcare, and community-based services. The position coordinates notifications and follow-up for physical and behavioral health hospitalizations, emergency room visits, referrals, and post-discharge appointments, helping clients move smoothly between services. The specialist contributes to panel population management and outreach, tracks healthcare utilization and clinical quality measures, and works with multidisciplinary teams, Integrated Team-Based Care leadership, and the Population Health team to identify care gaps and develop outreach strategies. The role also supports appointment scheduling, reminders, medical equipment orders, transportation, and coordination with external providers and payers. The position is based at the Garlington Health Center in Northeast Portland, Oregon, and follows a Monday–Friday, 8:30 a.m.–5:00 p.m. schedule. Work may take place in clinical offices, acute care settings, and community locations, including client residences, correctional facilities, shelters, hospitals, public places, and social service sites. Work is primarily during regular business hours, with possible after-hours crisis response. The position is represented by a labor union.

Requirements

At least one year of experience working in a healthcare setting.
Consumer or customer service experience.
Ability to commute to other locations.
Ability to perform CPR and First Aid and effectively use AED equipment.
Current BLS and First Aid certifications, which must remain current.
Ability to maintain required licenses, certifications, registrations, and other credentials in active, good standing status.
Understanding of the recovery model, motivational interviewing, illness management and recovery, evidence-based practices, and strength-based case management philosophies and strategies.
Ability to align with harm reduction philosophies, cultural responsiveness, and trauma-informed care.
Knowledge of panel management best practices.
Ability to operate computer hardware and software needed to perform job functions.

Nice To Haves

Bachelor of Arts degree in a related field, such as social or behavioral science or public health.
Certification as a QMHA or CADC.
Experience in behavioral health and panel management.

Responsibilities

Organize and analyze client-panel data to track healthcare utilization and needs, conduct outreach, and monitor clinical quality metrics.
Coordinate timely referrals with other client providers using electronic health records and collaborating with payer support.
Identify and engage clients in mental, physical, and oral healthcare services.
Monitor emergency department admissions and follow up with clients and the appropriate interdisciplinary team after discharge.
Rotate responsibility for monitoring after-hours/on-call reports for all ITBC clients and crisis services provided to assigned panel members.
Assist with scheduling external appointments and coordinate appointment reminders with the team administrator.
Coordinate medical equipment orders and transportation with the team administrator.
Attend scheduled team huddles, staff meetings, supervision sessions, and departmental meetings.
Collaborate with interdisciplinary teams and community services on diabetes management, mental health, preventive health, and health promotion.
Work with Integrated Team-Based Care leadership and the Population Health team to identify target populations and develop outreach strategies.
Attend health integration team meetings and collaborate with project leads to implement plans.
Follow compliance requirements, including mandatory reporting laws and HIPAA regulations.
Maintain accurate documentation in the Electronic Health Record System in accordance with agency policies and applicable regulations.
Complete annual employee training requirements.

Benefits

Generous paid time off; full-time employees earn six weeks of PTO in their first year.
Medical and dental coverage beginning the first of the month following hire.
VSP Vision Discount Plan.
403(b) retirement plan, eligible after 60 days, with immediate 100% vesting and a 1-to-1 company match up to 3% per pay period, plus the opportunity for an additional discretionary contribution of up to 5% at fiscal year-end.
Flexible Spending Account options for medical, dependent care, and transportation.
Short-term disability, long-term disability, and life insurance.
Paid bereavement and jury duty leave.
Length of Service Award.
Voluntary life insurance.
Supplemental insurance.
Student loan forgiveness options.
Employee Assistance Program.
Bike to Work reimbursement.