Care Transitions Advocate in Portland, OR

$80K - $100K(Ladders Estimates)

Ohsu Healthcare   •  

Portland, OR 97201

Industry: Hospitals & Medical Centers


Less than 5 years

Posted 44 days ago

Functions/Duties of PositionKEY RESPONSIBILITIES:

  1. Collaborates and consults with patient, families, professionals, and providers within the outside of OHSU to develop and implement outpatient care.
  2. Make referrals all levels of care by providing clinical information and documentation to support patient transitions of care to appropriate services. May include scheduling intake appointments, arranging follow up appointments, assisting patient with obtaining PCP.
  3. Complete follow up calls to patients to ensure a successful transition to care
  4. Develop strong, effective working relationships with interdepartmental specialists and programs, outside agencies, facilities, payers, and other relevant community resources in order to facilitate disposition solution for patients and families.
  5. Facilitates all necessary arrangements including:
  • Calls, photocopies, faxes, or mails clinical and/or referral information for outpatient services to:
  • Community substance use treatment agencies
  • Home Health and Hospice agencies
  • Primary care
  • Outpatient mental health care
  • Transportation vendors
  • SNF, ICF, AFH, RCF, and Assisted Living facilities
  • Shelter operators
  • Outside Case Managers
  • Medicaid Caseworkers
  • Insurance companies
  • Types letter of medical necessity, if needed
  • Compile and organize treatment resources that are easily accessible to all Bridge clinic care team members.
  1. Miscellaneous:
  • Creates and maintains forms and databases needed
  • Participates in orientation of new employees
  • Attends meetings as needed
  • Performs additional duties as needed
  • Obtains authorization from insurers using multiple insurance websites, phone and automated systems.


  • Master's in Social Work or Bachelor's Degree in Nursing or other combination of education, experience and training in healthcare discipline that provided the opportunity to manage care coordination for various patient populations.
  • Current Oregon RN license required if an RN is hired. Current Oregon LCSW license required if Social Worker is hired.
  • 3+ years work experience in healthcare disciplines, including but not limited to care coordination, case management, community mental health, chronic illness, patient education and complex social issues; other relevant experience, includes working with an adult underserved population and work in the Portland area safety-net.
  • Must have familiarity with common outpatient medications and general medical knowledge.
  • Valid OR/WA driver's license with an acceptable driving history and access to a car on a daily basis for home visits.
  • Demonstrated excellent written and verbal communication skills.
  • Must be flexible, self-motivated, proficient at multitasking, accustomed to frequent interruptions, and comfortable with change.
  • Must be comfortable working as part of an interprofessional team that includes physicians, social workers, peers with lived experience in recovery.
  • Requires knowledge of Microsoft Office Excel, Word, PowerPoint, and Outlook.
  • Must be able to perform the essential functions of the position with or without accommodation


  • LCSW preferred
  • Experience working in community substance use treatment or community mental health settings.

Valid Through: 2019-10-30

Ohsu Healthcare job

$66K - $+98K