Community Outreach Specialist

Location: Local Hybrid: Local to the McMinnville, OR area , with flexibility to work both remotely and/or in-person at YCCO's office in McMinnville. Most of the positions at YCCO are hybrid.

Department: Health Plan Operations FLSA Status: Exempt (Salaried)

Division: CHW Hub Physical Strength: Light (L)

Reports To: Clinical Care Manager Work Location Type: Local Hybrid

Supervisory Role: No Occasional Weekend Work: Yes

About Us: Yamhill Community Care is a nonprofit coordinated care organization dedicated to managing the healthcare for Medicaid members, covered under the Oregon Health Plan, in Yamhill County, as well as parts of Washington and Polk Counties. Our mission is to improve the quality of life of the communities we serve by coordinating effective care. Beyond healthcare, we also provide an Early Learning Hub, supporting families and children with essential resources and programs for early childhood development. Together, we're building a unified healthy community that celebrates physical, mental, emotional, spiritual, and social well-being.

Learn more about Yamhill Community Care:click here

Summary

The Community Outreach Specialist provides the opportunity to use life experience to support individuals navigating the health system and connect with needed resources. This role is responsible for working alongside the Member and healthcare teams to identify chronic conditions, unmet healthcare needs, social service needs, and issues that may be preventing access to use of available services. This position partners in preparing a plan to address Member needs, including goals to increase Member activation, and access and appropriate use of services. This position is primarily field- based in support of the Member performing home and community visits and attending provider visits. The position includes remote, office based, and field work, and community engagement. This position serves as an important link to Community-based health and social needs services to improve the quality and cultural competency of service delivery. This position also aids in building individual and community-based capacity by increasing health knowledge and self-sufficiency for Members and the community through a range of activities that include Member outreach, community education, informal counseling, social support and advocacy.

Essential Duties

1. Develops and maintains trusted relationships with Members by being patient, open-minded, non-judgmental, compassionate, flexible, responsible, and supportive, and by demonstrating follow-through.
2. Supports and educates Members on navigating the health care system, conducting field- based outreach and participating in the development of individual Member goals, which are documented in the Member’s Individual Care Plan.
3. Works collaboratively within and across team environments that may include other Community Health Workers (CHW), Clinical Support Specialists (CSS), Clinical Care Manager, RN Case Managers, Physical Health providers, Behavioral Health providers, dental service providers, and Community-based partner organizations.
4. Provides outreach and engagement activities to support Yamhill Community Care (YCCO) initiatives.
5. Demonstrates self-motivation and the ability to work independently.

Job Duties

Member Assessment & Care Planning

• Provides field-based support for Members through home and community visits, attending provider appointments, and being available to attend other health-service visits as may be indicated.
• Facilitates the creation of the Member Individual Care Plan (ICP) and for Members receiving Social Needs benefits, a Person-Center Service Plan (PCSP) working in collaboration with the Member, Member caregiver / representative, and others on the healthcare team to identify Member needs and challenges.
• Utilizes Member information to identify Member clinical and social needs to increase Member activation, access, and appropriate use of services.
• Evaluates and modifies Member support needs as necessary to assess progress, identify need changes and revise Member specific care plans.
• Engages with Members on a regular basis dependent on identified needs, to re-evaluate needs and set and/or revise Member-specific goals. Continue engagement with Members on a regular basis until goals have been reached or services are no longer required.
• Utilizes Motivational Interviewing and Trauma Informed communication methodologies working with Members in the development and updating of ICPs while honoring Member autonomy.
• Assists and educates Members in enrolling in community-based health and social service programs (e.g., SNAP, WIC, health support systems) and accessing community-based and social needs services such as transportation, housing, food, and climate-related support.
• Supports the coordination of and facilitates self-management classes and skill development events for the Member, as needed.

General Program Operations

• Promotes person-centered services by embracing and exhibiting YCCO Vision, Mission and Guiding Principles.
• Provides excellent customer service, meeting the needs of Members, following through, meeting deadlines, and interacting with others in a respectful and culturally appropriate manner to ensure equity and inclusion in the delivery of services.
• Maintains skills and knowledge in the performance of the role and educates self and others of resources available for populations served, including researching electronic and written materials and accessing other team members.
• Follows documentation standards to ensure Member information is captured in the Member Care Profile (Helios) in an accurate and timely manner.
• Assists in the development of new policies and procedures to improve program efficiencies.
• Establishes and maintains cooperative and productive working relationships with internal and external stakeholders contacted in the course of work.
• Possesses basic medical knowledge including the ability to recognize clinical and social risk factors and chronic disease conditions.
• This position supports occasional after-hours and weekend community events, with the ability to flex normal work time during the regular work week.

Essential Department & Organizational Functions

• Self-directed ability to function with minimal oversight from supervisor daily.
• Works effectively in a very fast-paced environment.
• Adheres to established internal control procedures for all contract functions.
• Ability to focus on and comprehend information, learn new skills and abilities, quickly assess a situation, and seek appropriate resolutions.
• Ability to tolerate and manage stress.
• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.
• Works closely with other YCCO departments, including Compliance to assist with audits; including the External Quality Review (EQR), as needed.
• Proposes and implements process improvements.
• Meets deadlines for completion of assigned responsibilities and projects.
• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
• Attends in person Annual Company Conference in Oregon, typically held in the fourth week of September.
• Demonstrates cooperation and teamwork using a professional and respectful demeanor.
• Provides cross-training on specific job responsibilities.
• Meets identified goals that contribute to departmental goals.
• Respectfully takes direction from Supervisor.
• Performs other duties as assigned.

**Knowledge, Skills, & Abilities **

• Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Ability to identify complex problems and review related information to develop and evaluate options and implement solutions.
• Ability to problem solve, analyze, and provide written documentation of analysis.
• Ability to build productive working relationships, problem solve and resolve conflicts successfully.
• Ability to function as an influential communicator and creative problem solver.
• Possess a high degree of initiative and motivation along with the ability to effectively collaborate and plan with coworkers and others.
• Knowledge of Social Determinants of Health and social challenges of Members gained through lived experience.
• Knowledge and ability in working with people in a non-threatening, firm yet respectful manner.
• Understanding of the nature of Member engagement and vulnerable populations and demonstrates a high level of interest in community engagement.
• Understanding and ability to maintain appropriate personal and professional boundaries while developing a close, effective relationship with members.
• Ability to identify challenges and successes and help create and modify plans to achieve success.
• Ability to build relationships and network with individuals at all levels, internal and external to the organization.
• Ability to understand the role of the Member’s preference in care success.
• Ability to learn and apply policies, regulations, requirements, rules around mandatory reporting and privacy and confidentiality.
• Ability to contribute to a cooperative and harmonious work environment by demonstrating a positive attitude.
• Ability to perform home visits, field work, and engage with community and clinical partners.
• Excellent organizational skills that include the ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix (cross-department) or shared resources across departments work model with a spirit of cooperation.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to communicate both professionally and effectively in all forms of communication.
• Ability to work in an environment with diverse individuals and groups.
• Ability to remain flexible, positive, and adaptable.
• Ability to work across the YCCO region and to work remotely, as needed.

Supervisory Responsibilities

This position has no supervisory responsibilities.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation(s) may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

• High school diploma or GED,
• Two (2) years of experience in a social service or similar community organization,
• Experience working with high-risk populations, conducting home and/or community-based visits, and/or providing support for members with chronic conditions.

OR:

• Any combination of education and experience that would qualify the candidate for the position.

Preferred:

• Associate degree in a health-related field.
• Bilingual skills (English / Spanish, Skills Pay available). Highly Preferred.

Certificates, Licenses and/or Registrations

Required:

• Certified Community Health Worker or the ability to obtain certification within six (6) months of hire,
• Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle,
• CPR Certification within six (6) months of hire.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.