THW Care Coordinator - Managed Care

THW Care Coordinator - Managed Care at Advanced Health Coordinated Care Organization

Base pay range: $19.00/hr - $26.00/hr salary: $18.60 - $26.33/HOURLY.

Classification: NON-EXEMPT | Status &

Schedule:

FULL-TIME, MONDAY – FRIDAY, 8AM – 5PM.

Reports to the Coos Bay office location, some remote work available.

DIRECTOR OF CARE COORDINATION.

Care Coordination.

• Minimum High School Diploma or GED.
• Current Community Health Worker Certification strongly preferred; may consider highly qualified applicant willing to obtain.
• Must complete continuing education to maintain THW certification in the state of Oregon.
• Minimum two to three years’ experience in a medical office or clinic setting.
• Motivational Interviewing experience required.
• Two to three years’ experience working with noted specialty population group strongly preferred.
• Bilingual preferred, qualified, certified, or willing to obtain.

• Identify risk factors and service needs impacting member outcomes, recognizing transitions from low to moderate or high risk.
• Utilize a trauma‑informed and culturally and linguistically appropriate approach to provide member‑focused care, ensuring services are respectful and aligned with members’ backgrounds.
• Assist members in navigating the continuum of care based on clinical needs, ensuring seamless transitions.
• Develop and implement individualized Intensive Care Coordination Plans (ICCP) for assigned members, ensuring they are member-centered and goal-focused.
• Interface with various agencies, including behavioral health providers, APD, DHS, and others to ensure coordinated and comprehensive care.
• Coordinate with healthcare providers to address unique member needs and ensure timely, effective care plans.
• Identify and report suspected abuse and neglect issues to mandated authorities as appropriate.
• Implement care plans in collaboration with members, providers, caseworkers, and other stakeholders.
• Respond promptly to requests for care coordination screening services and follow up on member needs.
• Work closely with behavioral health providers, crisis services, community partners, and interdisciplinary teams to deliver integrated care.
• Conduct outreach calls for members transitioning risk levels and perform annual HRAs for those with active care plans.
• Provide various forms of care coordination (face‑to‑face, telephonic, video) to ensure timely communication with members and families.
• Maintain and manage a caseload of members, supporting their health progress according to established policies.
• Perform health risk screenings to assess members’ health and overall well‑being, documenting findings to inform care plans.
• Familiarize members with available resources in Coos and Curry counties, ensuring access to the best services.
• Track and document member progress, responding to any triggering events requiring additional services.
• Develop and maintain strong relationships with members, their care teams, and community resources.
• Actively participate in interdisciplinary teams to support integrated care plans for complex members.
• Provide coaching and training to new employees on care coordination services, as needed.
• Provide education for network providers on care coordination services and other support options.
• Ensure adherence to company policies, handle confidential information securely, and maintain compliance with regulatory requirements.
• Participate in quality and organizational process improvement activities as requested.
• Perform other duties as assigned to support organizational goals and member outcomes.

• Participate in quality and organizational process improvement activities when requested.
• Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities.
• Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner.
• Work…