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

Department: Health Plan Operations FLSA Status: Non - Exempt

Reports To: Care Management Manager Physical Strength: Light (L)

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

This position provides the opportunity to use lived life experience to support individuals navigate the health system and connect with needed resources. This role is responsible for working alongside the member and healthcare team to identify chronic condition(s), unmet healthcare needs, social service needs, and issues that may be preventing access of use of available services. This position partners in preparing a plan to address these needs, including goals to increase patient activation, access and appropriate use of services. This position includes remote, office based, and field work. such as performing home visits and community engagement.

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. Helps participants learn skills to access, enroll in and utilize services and resources on their own by providing motivational coaching, helping members make and get to appointments, and helping members overcome resistance to using services.
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, and dental service providers.
4. Outreach and engagement activities to support Community Care Organization (CCO) initiatives.
5. Coordinates initiatives and assists with data reviews and processes.

_ Please note that all details pertain to both Level I & II unless Level individually specified_ .

Job Duties

Program & Data Coordination

• As assigned, supports preparing, implementing, and marketing programs and initiatives to enhance member engagement. (Level I)
• Assists the Care Management Manager in preparing, implementing, and marketing programs and initiatives to enhance member engagement (Level II)
• Collects data. (Level I)
• Collects and synthesizes data and tracks and evaluates effectiveness. (Level II)
• Provides recommendations for program and/or process adjustments.
• Assists with the development of new policies and procedures.

Member Assessment & Care Planning

• Works with the member and the healthcare team to identify member needs and challenges.
• Utilizes the information to develop CHW plans or contribute to Care Management (CM) plans for the member to increase patient activation, access, and appropriate use of services.
• Evaluates and modifies support as necessary by working with members and teams to assess progress, identify needed changes and revise plans.

Member & Network Relations

• Engages with members regularly during the first stage of connection and as needed throughout the transition and shows availability as needed.
• Establishes and maintains cooperative and productive working relationships with internal and external stakeholders contacted in the course of work.

Coaching

• Mentors and coaches members in working through plans, while respecting members and their choices. (Level I)
• Mentors and coaches’ members in working through plans, while respecting members self-determination. (Level II)
• Assists and educates members in enrolling in health and social service programs (e.g. SNAP, WIC, health support systems) and accessing community services such as transportation, shelter, food, etc.
• Works with team to identify tools and resources to use in mentoring, reinforcing successes, and providing feedback.
• Supports the coordination of and facilitates self-management classes and skill development events, as needed.
• Trains and mentors new CHW employees. (Level II)

Other

• Serves as an advanced resource to other CHW. (Level II)
• Promotes person centered services by embracing and exhibiting Yamhill Community Care’s (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 to perform the job and educates self and others of resources available for populations served, including researching electronic and written materials and accessing other team members.
• This position supports occasional after-hours and weekend community events, with the ability to flex normal work time during regular work week.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.
• Participates in the preparation and submission of regulatory and contract required deliverables.
• 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.
• 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.
• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.
• Respectfully takes direction from Supervisor.
• Other duties as assigned.

Knowledge, Skills, & Abilities

• Ability to learn and utilize available resources and services.
• Knowledge of social determinants of health and social challenges gained through lived experience.
• Knowledge and ability in working with people in a non-threatening, firm yet respectful manner. (Advanced knowledge, Level II)
• Understanding of the nature of member engagement and vulnerable populations and demonstrated high level of interest in community engagement. (Strong understanding, Level II)
• Understanding and ability to maintain appropriate personal and professional boundaries while developing a close, effective relationship with members. (Strong understanding, Level II)
• Advanced knowledge of basic managed care concepts and preferably the OHP. (Level II)
• Ability to identify challenges and successes and help create and modify plans to achieve success.
• Ability to build (and leverage, Level II) 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.
• Demonstrated ability to serve as a technical resource to other Community Health Workers. (Level II)
• Excellent organizational skills including 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 or shared resources across departments work model.
• 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 while being open-minded and non-judgmental, including working with others who may hold different values / experiences, such as cultural needs, language, economic status, life experience, etc.
• 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

Level I 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 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.

Level II Required:

• High school diploma or GED.
• Three (3) years of work experience in a social service or similar community organization.
• Experience should include minimum of two (2) years as a Community Health Worker working with high-risk populations, conducting home 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:

• 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.

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 accommodations 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.