Oregon Health & Science University
Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or email@example.com.Location:
Nursing-Care ManagementPosition Type:
Regular Full-TimeJob Type:
AFSCME union representedDepartment:
OHSU Health Plan ServicesSalary Range:
Commensurate with ExperienceSchedule:
Monday - Friday, normal business hours. Hours not to exceed 40 hours per week.HR Mission:
The Health Engagement Specialist (HES) works both independently and collaboratively with members of the multi-disciplinary care team and could either be a Social Worker or Registered Nurse. The HES performs a variety of functions in the performance of duties that includes on-site (face-to-face) and telephonic outreach, behavioral health, disease and/or care management, care coordination, education, support and navigation to plan members participating in the OHSU IDS Health Plan program with the goal of supporting healthy life choices and to reduce long term effects of chronic illness. The individual in this role performs other clinically based activities to assist in the coordination of care between the member, his/her provider(s), health care facilities, and community-based health organizations, brief problem solving, consultation, referrals to community resources, and health literacy educations. The HES enhances the quality of member management by promoting continuity of care and cost effectiveness through whole person care management, care integration, and care coordination across the continuum of health care services.Function/Duties of Position
- Provides on-site (face-to-face) and telephonic outreach, disease management and/or care management, education and other clinically-based activities for OHSU Health members.
- Conducts assessments, develops plans of care and interventions to address social determinants and potential barriers to care, setting goals for plans of care and behavioral modification within his/her scope of practice.
- Collaborates with OHSU Health member's medical and health community-based providers (that may include the primary care provider (PCP), specialist provider, behavioral specialists, or others as may be indicated) regarding the member's treatment needs and plan of care, identifying creative strategies to address psychosocial issues. The frequency of contact is determined based on the member's risk acuity ranking and clinical need.
- Provides education and guidance to providers and the care team on the social determinants of health and the effect these have on the individual member.
- Routinely documents all member interactions and member engagements in the electronic medical record (EMR) to ensure a longitudinal record is maintained of all member interactions. Collects clinical engagement data and enters information into the EMR for tracking and metric purposes.
- Monitors and evaluates the services and community-based resources necessary to respond to the member's individual health care needs.
- Ensures day-to-day processes are conducted in accordance with nationally accepted standards (NCQA, URAC and other regulatory standards).
- Fosters positive and professional relationships and acts as a liaison with internal and external customers to ensure effective working relationships.
- Maintains medical record confidentiality at all times through the proper use of computer passwords, maintenance of secure files; adherence to HIPAA guidelines and policies.
- Utilizes proper telephone and personal etiquette and judicious use of other verbal and written communications, following OHSU and OHSU Health policies, procedures and guidelines.
- Works collaboratively with the interdisciplinary team in identifying opportunities for improvement and participating in the development of new approaches to enhance effectiveness in work performed.
- Follows OHSU and OHSU Health telecommuting policies and procedures as a member of the field-based staff.
Master's in Social Work or Bachelor's Degree in Nursing or other combination of education, experience and training in healthcare discipline that provided the opportunity to manage care coordination for various patient populations.
Current Oregon RN license required if an RN. Current LCSW license required if Social Worker.
Three-plus (3+) years, experience in healthcare disciplines, including but not limited to care coordination, case management, community mental health, chronic illness, patient education and complex social issues; other relevant experience, includes working with an adult underserved population. Required:
- Clinical assessment skills, consistent with state licensure scope of practice.
- Ability to assess patient health and mental status, consistent with state licensure scope of practice requirements.
- Able to prioritize and target interventions, consistent with state licensure scope of practice requirements.
- Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
- Organizational skills with the ability to handle multiple tasks and/or projects at any one time.
- Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from different departments and/or agencies within and outside OHSU and OHSU Health.
- Strong telephonic communication and interviewing skills, particularly motivational interviewing.
- Analytical and interpretation skills including departmental, utilization, financial and operations data.
- Decision-making skills with the ability to investigate and weigh alternatives, integrate data, and select the most appropriate course of action that meets the best-interest needs of the member and provides the greatest benefit to the organization.
- Creative- and critical-thinking skills with the ability to consider new ideas that will lead to process and team improvements.
- Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.
- Problem-solving skills with the ability to look for the root cause of issues and implementable, workable solutions.
- Interpersonal skills with the ability to work in a fast-paced environment with the ability to participate as an independent contributor with little direct supervision or as an active team member depending on the circumstance or need.
- Attention to detail and a track record of producing high-quality and accurate work that reflects well on the organization.
- Knowledge and experience in working with computer systems and electronic medical records.
- Able to travel within the tri-county area with an active and unrestricted driver's license, reliable transportation and active automobile insurance coverage.Preferred Qualifications
- Experience working with Oregon Health Plan (OHP) members.
Knowledge and experience working within Epic as the electronic medical record.
- Knowledge social determinants.
- Knowledge of the influence trauma may play in member engagement.
- Knowledge of Medicare and Medicaid.
- Knowledge of adult learning and behavior change principles.
- Knowledge of community-based resources.
- Demonstrated skills in motivational and health coaching, patient advocacy, health promotion, disease prevention, patient education and resource management.
- Demonstrates knowledge of NQCA and Case Management guidelines.
- Provides care management services appropriate to the age of the member served - neonate, infant, pediatric, adolescent, adult and geriatric patients based on the principles of growth and development and life stages.All are welcome