Care Integration Specialist

To coordinate and administer all administrative aspects of patient flow through OHSU Urologys Transgender Health Program (THP) Surgical Specialty under the guidance of clinic management and the THP medical director and in collaboration with THP Clinical Manager. This includes duties related to program administration coordination of patient care through pre- and post-operative phases of care management of patient tracking systems and outreach coordination with THP Behavioral Health Team and other internal and external partners. This position will also assist with the patient scheduling and patient flow process providing clinic scheduling assistance and phone back-up.

Customer Service:

• Provide the highest level of customer service to both external customers (patients and their families referring providers insurance carriers etc.) and internal customers (OHSU health care providers and staff) that meet or exceed the service standards of the health care industry. This duty includes prompt and professional communication efforts face-to-face customer contact skills crisis management facility with available information technology standard complaint processing flexible coverage of internal service needs and the continuous application of process improvement methods and skills.

Patient management:

• Uses EPIC to reach out to patients by making proactive calls MyChart messages and letters to assist with them accessing services and resources in navigating the health care system
• Supports the team by entering referrals and interacting with the care team to ensure patient is moving along in their preoperative process
• Collaborates with THP Behavioral Health Team if/as needed

Care coordination:

• Assumes a lead role in working with patients to help them through their pre-operative requirements and tracking their progress though the pre-op phase
• Assists with questions regarding referrals and pre-operative requirements
• Collaborates closely with the THP team in facilitating care coordination referrals and access to services as may be indicated for patients
• Identifies and requests needed records to ensure high quality coordination of care
• Monitors and evaluates the services and community-based resources in collaboration with the THP Behavioral Health team necessary to support THP patients preoperative needs
• Liaises with internal and external stakeholders to coordinate necessary care pre and post operatively

Communication:

• Provides program information to patients and gathers information for specific visits
• Prioritizes and responds to patient questions via MyChart phone email and fax in regards to scheduling and care issues within scope.
• Document compose and prepare confidential correspondence reports and related materials to support the Care Integration and Coordination process
• Escalates all issues outside scope as appropriate.
• Attends regular meetings with external and internal partners to coordinate patient care identify opportunities to improve communications and problem solve root causes for delays and gaps in care.

Documentation/Data management:

• Routinely documents all relevant patient interactions and engagements in Epic to ensure a longitudinal record is maintained of all patient interactions.
• Collects clinical and engagement data and enters information into the Epic for tracking and metric purposes.
• Documents legibly concisely correctly and completely to ensure team can accurately assess the status of care needs.
• Uses approved clinical resources and follows procedures appropriately.
• Participates as assigned with database input.
• Issues patient safety alerts to providers and helps manage the patients affected.
• Collects and enter data into patient tracking database
• Generates reports from and audit data in database
• Works with IT staff on database upgrades
• Monitors tracking tools and provides providers with real-time updates as appropriate.
• Initiates and implements processes to facilitate continual improvements related to data collection.

Teamwork and Collaboration:

• Participates with team members in regular huddles discussing daily work for the team to align with OHSU service standards. Must have strong communication listening skills and awareness of self.

Other tasks as assigned

• Associatedegreeina healthcarerelatedfieldthatmay include suchareasas nursing community health educationpsychologyor sociologyis required.
• Bachelors degree inahealth care related fieldthatmayinclude such areasascommunityhealth education psychologyorsociologyis preferred.
• Minimum two (2)years of healthcaresetting such ashospital clinicorhealth plan experienceis required.
• Priorexperiencein casemanagementin a health caresetting such ashospital clinicorhealth planispreferred.
• Basic computer keyboarding skills including typing of 40-50 wpm. Proficient computer skills including word processing. Extremelyhigh level of attention to detail. Strong customer service orientation. Must have excellent verbal and written communication listening skills and awareness of self. Demonstrated reliable attendance record.

• Prior experience in case management in a health care setting such as hospital clinic or health plan is preferred.
• Experience working with an electronic health record. Scheduling Experience.
• Experience working in transgender health care
• Medical terminology. Ability to learn new computer sills and systems.
• Epic

• Typical schedule: 7:30am-4:00pm M-F occasional nights and weekends
• May be able to telecommute part-time
• When onsite travel between meeting locations including using the Portland Ariel Tram
• Ability to sit stand reach lift bend and stoop
• Frequent sitting standing reaching typing and lifting up to 3 lbs. Occasionally lifting up to 20 lbs
• Heavy use of computers and long periods of sitting
• Must be able to walk when necessary between OHSU locations in all weather conditions
• Regularly required to talk hear and/or communicate with others by phone in person and through electronic means
• Able to handle a fast paced work environment with multiple time sensitive competing demands
• Requires ability to respond quickly and appropriately to urgent situations that may arise