Clinical Coordination Specialist- Primary Care

Job Overview

Location/Schedule: The position is located at located at the Woodland Park Health Center in Portland, OR. The schedule for this position is Monday through Friday, 8:30 a.m. to 5:00 p.m.

Position: Clinical Coordination Specialist

Program: Integrated Team Based Care

Cascadia’s Mission and Vision:  

Mission: Cascadia Health delivers whole health care – integrated mental health and addiction services, primary care, and housing – to promote hope and support the well-being of the communities we serve. 

Vision: We envision a community where everyone benefits from whole health care, experiences well-being, and has a self-directed, connected life. 

Position Description: The Clinical Coordination Specialist plays a pivotal role in facilitating comprehensive client care across services received by ITBC clients, including mental health, addiction medicine, physical healthcare, and community-based services. This position involves creating notifications for physical and behavioral hospitalizations, coordinating emergency room (ER) visits, and managing follow-up appointments after discharge. The Clinical Coordination Specialist manages referrals between services as needed, ensuring seamless transitions for clients across all healthcare services. They engage in Integrated Team-Based Care panel population management and outreach for the client population, contributing to the work of several multi-disciplinary teams in collaboration with Integrated Team-Based Care leadership, and analyzing and bridging the gaps that may exist in systems of care.

Essential Responsibilities

This position description is not intended to be an all-inclusive list of responsibilities, skills, or working conditions associated with the position. Management reserves the right to modify, add, or remove duties as necessary. 

General

• Organize and analyze data from client panels to track healthcare utilization and needs, conducting outreach as necessary, tracking quality clinical metrics.

• Coordinate referrals with other client providers in a timely and professional manner, utilizing electronic health records and collaborating with payer support.
• Identify and engage clients in various healthcare services (mental, physical, oral).
• Monitor emergency department (ED) admissions and follow up with clients and the appropriate interdisciplinary team post-discharge.
• Serve on rotation to monitor after-hours/on-call reports for all ITBC clients and crisis services provided for assigned panel members.
• Assist with scheduling external appointments; coordinate with team administrator to ensure clients receive appointment reminders.
• In collaboration with team administrator, coordinate medical equipment orders and transportation for clients.
• Attend all scheduled team huddles, staff meetings, supervision sessions, and departmental meetings to stay informed and engaged with team objectives.

Collaboration

• Collaborate with interdisciplinary teams and community services to address clients’ needs in diabetes management, mental health, preventative health, and health promotion.
• Work closely with the Integrated Team-Based Care leadership and the Population Health team to identify target client populations and develop outreach strategies.
• Attend team meetings focused on health integration and collaborate with project leads to implement plans.

Compliance

• Adhere to all compliance requirements, including mandatory reporting laws and HIPAA regulations.
• Ensure that all documentation is accurate and maintained in accordance with agency policies and local, state, and federal regulations through the Electronic Health Record System (EHR).
• Complete all annual employee training requirements to ensure ethical practices and professional development, maintaining compliance with organizational standards.

Qualifications

Education:

• Required: BA in a related field (e.g., social or behavioral science, public health) or certification as a QMHA or CADC is preferred but not required.
• Required: At least one year of experience working in a healthcare setting. Consumer/customer service experience is required. Experience in behavioral health and panel management is strongly preferred.

Specialized Knowledge, Skills, & Abilities:

• Understanding of recovery model, motivational interviewing, illness management and recovery, evidence-based practices, and strength-based case management philosophies and strategies.
• Understand and align with harm reduction philosophies, cultural responsiveness, and trauma informed care.
• Knowledge of panel management best practices.
• Operate computer hardware and software at a level needed to effectively perform job functions.

Other:

• Ability to commute to other locations.  
• Ability to perform CPR, First Aid, and effectively use AED equipment. BLS/ First Aid certifications are required and must remain current. 

Working Conditions

Environmental: Work is performed in one or more of the following: clinical office, acute care settings and community setting including client residences, correctional facilities, shelters, hospitals, public places and other social service sites. Meal periods and breaks are subject to interruption. Much of the work is performed during regular business hours with the potential of extending into afterhours only for crisis response. Universal Precautions and remaining alert to the environment are critical to address the potential for violent behavior, exposure to disease, biohazards, noise, and contaminants.

Mental: The work assigned is diverse and involves addressing new and unusual circumstances in which outcomes may negatively affect costs, employee morale or clients. The work regularly involves a degree of unpredictability and disruption of planned tasks requiring a flexible time management approach. In addition, this position requires exercising sound judgment. Decision-making may occur in a moderate to high stress situation where a client may be experiencing a crisis. 

Cascadia is an Equal Opportunity employer.  We celebrate diversity and are committed to creating an inclusive environment for all employees.  If you need assistance or an accommodation due to a disability, you may contact us at 503.963.7654 or at [email protected]

This position is represented by a labor union.

Employees are responsible for obtaining and maintaining all licenses, certifications, registrations, and other credentials required for their position. Required credentials must remain active and in good standing as a condition of employment. Candidates are encouraged to familiarize themselves with any applicable credentialing requirements, including associated fees and renewal or maintenance obligations, prior to applying.

Benefits

We offer generous benefits for our full-time and part-time employees (20 hours + pro-rated) including:

• Generous Paid Time Off Package - Full-time employees earn 6 weeks of PTO in their first year!
• Medical and Dental Coverage (begins 1st of the month following hire date)
• 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 (up to 5%) at the end of the fiscal year.
• Flexible Spending Account (FSA) (Medical, dependent care, and transportation options)
• 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

Wellness Benefits:

• Employee Assistance Program (EAP)
• Bike to Work Reimbursement

Starting Rate Range in USD ($)