Intensive Care Coordinator

CareOregon-posted 3 days ago

$81,000 - $99,000/Yr

Full-time • Mid Level

Hybrid • Portland, OR

1,001-5,000 employees

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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. NOTE: This hybrid role averages 2-3 partial days per week in the community, with the remainder of work done remotely from home.

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.
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.
Provide telephonic 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.
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.
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 substance use topics and issues.
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
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.
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.
Participate in quality and organizational process improvement activities and teams when requested.
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.
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.

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
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 of co-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 participate in work-related continuing education when offered or directed
Ability to provide excellent customer service and verbal and written communication
Basic word processing skills
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 operate a motor vehicle

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)

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.
CareOregon 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.

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