30 days old

Care Coordinator, Transitional Care

Umpqua Health
Roseburg, OR 97470
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  • Job Code
Part Time - Regular
Roseburg, OR, US


The Care Coordinator, Transitional Care is part of an innovative, community-based team.?This position works collaboratively with members who may have complex medical/psychosocial/ addiction issues and their families/caregivers as well as with members of multidisciplinary teams (MDT) to help members transition from acute care to their community care setting. Using evidence based transitions interventions, the Transitions Nurse will engage members and providers across the care continuum to identify and address risks associated with hospital readmission and barriers to care.? This position will engage with members in person, and telephonically, in the hospital, clinic setting, members homes and/or community settings. The Transitional Care and Outreach Team is part of an advanced illness initiative which aims to improve quality of care, coordinate care across the continuum, reduce hospital readmissions, and increase access to end of life care.

  • Provides coordination of care, benefits, community resources and referrals to facilitate safe transitions between care settings
  • Coordinates/updates the plan of care that includes self-management and member specific goals.? Unlike other nursing roles, this role does not direct or lead the care planning process; rather, it contributes to a multidisciplinary care planning process
  • Collaborates with members of multidisciplinary medical teams to provide a process that enhances patient satisfaction, efficiency of time and resources, and improved outcomes
  • Uses evidence based approaches to patient education regarding members health status, disease state, red flag symptoms, symptom management, medication management and self-management strategies
  • Utilizes evidence-based guidelines and best practices related to disease-specific assessment and interventions
  • Collaborates with care coordinators, multidisciplinary providers, benefit specialists, behavioral health specialists, pharmacists, vendors, and social services to enhance member satisfaction, conserve time and resources, identify barriers, improve outcomes and reduce avoidable readmissions
  • Plans, participates in, and facilitates care conferences for medically complex members and others as deemed appropriate (including the clinic discharge process)
  • Coordinates the plan of care, assesses members stability and ability to adhere to the prescribed treatment and self-management plan
  • Incorporates members right to choice of treatment or refusal of treatment
  • Works with members effectively in the home setting as appropriate to assess safety and coordinate services to address needs or opportunities to promote wellness
  • Establishes a trusting relationship with the member, their family and other relevant parties involved to facilitate access to needed services to meet health needs
  • Assesses the needs of each member, advocates as appropriate and links member to needed services using stewardship principles and following organizational policies
  • Creatively utilizes available community resources as an adjunct to health plan benefits and follow-up to determine if these are received by the member
  • Involves Medical Director for member resource needs that exceed Oregon Health Plan Medicaid and/or Centers for Medicare and Medicaid Services Medicare benefit packages or for situations that appear to warrant medical director assistance or review
  • Makes referrals to community programs/services as appropriate
  • Assists in mentoring newly hired staff; provides coaching and training on specific job responsibilities
  • Follows departmental, organizational and clinic?policies and procedures
  • Manages an efficient and effective case load
  • Reports to work as scheduled and follow attendance policies; maintain agreed upon work schedule
  • Participates in quality and organizational process improvement activities and teams when requested
  • Effective at establishing and maintaining key community partnerships
  • Participates in work related continuing education when offered or directed
  • Maintains working knowledge of OHP/SNP benefits
  • Reports member complaints to QI for investigation and follow-up, per protocol
  • Proposes and implement process improvements
  • Meets deadlines for completion of daily, weekly and month-end reporting
  • Demonstrates cooperation and teamwork
  • Meets identified business goals that contribute to departmental goals
  • Other duties as assigned.



Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.


Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.

Be a Team Player

Support and assist your team members. Be available to help, and learn from your team. Keep an open mind to feedback and earn trust of staff.


Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.


Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.

  • Working with a variety of personalities, maintaining a consistent and fair communication style.
  • Satisfying the needs of a fast paced and challenging company.
  • Limited Community Resources

  • Current unencumbered Oregon Nursing license (LPN/RN) and a current drivers license required
  • Dependable transportation, with evidence of insurance.
  • Minimum 1 year nursing experience required.?
  • Valid drivers license, acceptable driving record, and automobile liability coverage or access to an insured vehicle.?
  • Additional experience in home care, advanced illness, palliative care, hospice, and primary care or case management
  • Bachelor of Science in Nursing is preferred.
  • Knowledge of the impact of trauma, generational poverty and social determinants of health on the members ability to develop and follow self-care goals to improve health outcomes
  • Comfortable supporting members at the end of their lives; including facilitating advanced care planning
  • Ability to be sympathetic to a member, family or caregivers needs, and be able to deal with people in various states of pain, trauma and tragedy
  • Knowledge of community resources to support a complex, vulnerable population
  • Ability to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying a members multidisciplinary needs, developing health goals and communicating with providers
  • Ability to teach positive communication and problem solving skills
  • Ability to coordinate with benefits administration staff and clinic providers to ensure consideration is given to unique needs in care planning
  • Strong commitment to multidisciplinary collaboration and communication
  • Ability to work with members from various cultural and ethnic backgrounds; demonstrating cultural knowledge and sensitivity to populations being served
  • Ability to work independently
  • Adaptable in fast paced environments, has excellent time management skills and demonstrates flexibility in operating in different work settings with superb attention to detail
  • Able to initiate and answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information
  • Excellent verbal and written communication skills
  • Strong computer skills and knowledge of Microsoft Outlook and Office (Word, Excel)
  • Possess a high degree of initiative and motivation along with the ability to effectively communicate and collaborate with coworkers and others.


Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds.


Posted: 2021-05-22 Expires: 2021-06-23

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Care Coordinator, Transitional Care

Umpqua Health
Roseburg, OR 97470

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