Clinical Coordination Specialist- Primary Care

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…