Care Integration Specialist

Care Integration Specialist

The Care Integration Specialist, working as a member of the interdisciplinary team, provides assistance and support to the Clinician team. This position helps facilitate a safe handoff plan back to the community, providing patients and care partners with services and resources as appropriate. This position collaborates with the care team and the patient/care partner to create an appropriate plan based on the resources available. This position manages a resource guide to be utilized for the care coordination process and is the point person for external vendors, insurances and other care team members. This position functions under the direct supervision and management of the Administrative Director of the PCO/Movement Disorders Division. Activities are related to care coordination, care partner support, insurance as well as managing external resources.

Function/Duties of Position

Care Coordination:

• Coordinate community resources based on payer coverage, including obtaining prior authorizations (e.g., DME, home health, SNF) and submitting required clinical documentation.
• Collaborate daily with nursing and the care coordination team to review patient needs, proactively develop transition plans, and track progress.
• Assess and prioritize patient and care partner needs (medical, social, financial), and develop safe, feasible transition plans in partnership with patients/care partners using available resource guides and vendor options.
• Co-manage transition planning by identifying appropriate community resources, communicating options to patients and the care team, and documenting plans and updates in the medical record.
• Serve as a liaison across the interdisciplinary team, providing timely updates on transition plans, barriers, and progress.
• Facilitate coordination of supportive services (e.g., meal cards, AFS checks, family housing) in collaboration with Social Work.
• Communicate directly with patients and care partners to confirm preferences, provide updates, and address questions regarding services and transitions.
• Arrange and coordinate services by communicating with external partners, including:
  • Home Health and Hospice agencies
  • Infusion vendors
  • DME vendors
  • Transportation vendors
  • SNF, ICF, AFH, RCF, and Assisted Living facilities
  • Outside Case Managers
  • Community Neurologist
  • Community Primary Care Providers
  • Medicaid Caseworkers
  • Insurance companies
  • Shelter operators
  • Types letter of medical necessity, if needed
• Ensure follow-through on all referrals and services by tracking status and confirming initiation of approved resources.
• Arrange or coordinate follow-up appointments (e.g., primary care, specialty care, labs, radiology).
• Maintain accurate, timely documentation of all coordination activities, referrals, and updates in the medical record.
• Perform other non-licensed duties related to transitions of care as assigned.

Miscellaneous:

• Support data tracking related to care partner research.
• Support any data related to Center of Excellence requirements.

Required Qualifications

• Associate degree in a healthcare related field that may include such areas as nursing, community health education, psychology or sociology is required.
• Bachelor's degree in a health care related field that may include such areas as community health education, psychology or sociology is preferred.
• Minimum two (2) years of healthcare setting, such as hospital, clinic or health plan, experience is required.
• Prior experience in case management in a health care setting, such as hospital, clinic or health plan is preferred.
• Demonstrated excellent written and verbal communication skills.
• Experience working with patients and their families.
• Must be flexible, self-motivated, proficient at multitasking, accustomed to frequent interruptions, and comfortable with change.
• Must be knowledgeable in medical and insurance terminology and procedures, and patient discharge process. Familiarity with insurance UR and disability qualifications.
• Able to work independently with minimal oversight.
• Must have time management skills with competing priorities.
• Able to maintain a commitment to their coworkers.
• Demands critical thinking.
• Requires knowledge of Microsoft Office Excel, Word, PowerPoint, and Outlook.

Preferred Qualifications

• Prior experience in care coordination in a health care setting, such as hospital, clinic or health plan is preferred.
• Experience using EPIC software.
• Experience using Kronos timekeeping software.
• Experience using Crystal Reports software.

Additional Details

Working Conditions:

• This position requires staff to be able to commute onsite a minimum of 60% of the time or more.
• Staff may be sitting at their desk up to 70% of the time
• Staff may be required to walk around the hospital up to 30% of the time
• This position may be located on patient units and requires direct patient interaction in their room.
• This position may be exposed to contact precautions.
• Requires prioritization.
• Frequent interruptions in an environment of frequent change and fluctuations.
• For inpatient units accepts accountability and responsibility.
• Subject to computer work for several hours, as needed.
• Able to utilize office equipment within work area.

Physical Demands and Equipment Usage:

• Standing: On concrete, vinyl, or carpeting up to 4 hours per day and intermittently.
• Sitting: Chair or stool continuous up to 8 hours per day and intermittently.
• Changing Position: Intermittently, as needed.
• Walking: Inermittently up to 4 hours per day on concrete, vinyl, and carpeting.
• Bending: From the waist and knees, frequently throughout the day.
• Reaching/Handling: Fine manipulation, repetitive, gross motor requiring full ROM in upper extremeties, including overhead reaching.
• Climbing: Staircase, intermittently throughout the day.

Why Apply To OHSU?

We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington. All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact View email address on click.appcast.io