Job Description

Job Description

Job Description

The Care Coordinator in Umpqua Health’s Behavioral Health department plays a key role in delivering trauma-informed, culturally responsive care coordination across a range of settings, including inpatient facilities, in-home services, and community-based programs. This position works collaboratively with members, families, providers, and community partners to assess individual needs, create personalized care plans, connect members to essential services, and support smooth, coordinated transitions throughout the continuum of care.

• 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.

• Bachelor’s degree in behavioral science, social science, or a related field and a current license that qualifies you to sit for the Certified Case Manager (CCM) exam (e.g., RN, LCSW, LPC, CRC, CDMS, or MA).
• Minimum of two (2) years of health case management experience.
• Must obtain Certified Case Manager (CCM) certification within one year of hire.
• Knowledge of trauma-informed care, motivational interviewing, and behavioral health service delivery systems.
• Strong interpersonal skills with the ability to build rapport and trust with members from diverse backgrounds.
• Effective communication skills, both verbal and written, to clearly collaborate across care teams and engage with members.
• Excellent organizational and time management skills, with the ability to prioritize competing demands and meet deadlines.
• Problem-solving mindset with the ability to adapt to complex and evolving member needs.
• Demonstrated cultural humility and ability to work respectfully with individuals of varied backgrounds, identities, and experiences.
• Comfortable working independently in a remote setting, with a reliable internet connection (minimum 50 Mbps download / 10 Mbps upload).
• No current suspension, exclusion, or debarment from participation in federal healthcare programs (e.g., Medicare/Medicaid).

About Umpqua Health

At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Umpqua Health serves Douglas County, Oregon, where we prioritize personalized care and innovative solutions to meet the diverse needs of our members. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together. Join us in making a difference at Umpqua Health.

Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.

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