- Conduct member outreach and build rapport by engaging individuals in settings that are most comfortable and accessible to them, including their homes, via telehealth, or in community-based locations, ensuring trust and transparency from the first interaction.
- Perform comprehensive, trauma-informed assessments that evaluate behavioral, physical, and social health needs, including mental health history, substance use, functional ability, environmental safety, and support systems.
- Develop individualized, strengths-based care plans tailored to member-identified goals, risk factors, and clinical needs, with the goal of improving overall well-being, reducing avoidable utilization, and enhancing member autonomy.
- Deliver ongoing care coordination and coaching that supports member engagement, facilitates behavior change through motivational interviewing techniques, and reinforces treatment plan adherence in alignment with evidence-based practices.
- Actively manage transitions of care by coordinating discharge planning and follow-up care for members moving between care settings, such as hospitals, residential treatment facilities, and long-term care, with a focus on continuity and reducing readmissions.
- Collaborate with multidisciplinary teams and community partners including behavioral health providers, primary care, DHS, Developmental Disability programs, crisis services, and local housing or food support agencies to ensure integrated and holistic care.
- Monitor and track service referrals and follow-through, documenting outcomes of member engagements, home visits, and all relevant activities in compliance with case management standards and regulatory requirements.
- Facilitate access to critical services and supports, including helping members complete necessary forms, coordinating emergency assistance, and submitting requests for flexible spending funds as appropriate to address social determinants of health.
- Ensure compliance with state and federal guidelines, maintaining up-to-date knowledge of Oregon Administrative Rules (OAR), Medicaid and Medicare requirements, and member rights under the Oregon Health Plan.
- Educate members and their families on healthcare navigation, consent for information sharing, treatment options, rights and responsibilities, and how to access behavioral health and community-based services.
- Participate in and contribute to Interdisciplinary Team (IDT) meetings by sharing updates, aligning on shared goals, and problem-solving collaboratively with internal colleagues and external partners to support positive health outcomes.
- Perform other duties as assigned to support Umpqua Health’s Vision, Mission, and Organizational Values.
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