• Serve as the first point of contact within the Care Coordination Team for members or providers who call CareOregon Regional Care Team (RCT) phone lines requesting assistance with physical and behavioral health needs • Answer phone lines and check voicemails left on RCT line daily and address any needs identified • Coordinate referrals from members, providers, community partners, and internal CareOregon departments and teams • Provide call escalation support for Customer Service Representatives when necessary • Determine navigation, care coordination and/or resource needs in response to calls into the Regional Care Team (RCT) phone lines • Identify members in crisis, triage needs requiring urgent attention, and help de-escalate high-need callers • Triage appropriate referrals and help determine care coordinator assignment for RCT clinical care coordinators based on identified member needs • Provide telephonic-based physical and behavioral health care coordination to eligible members and families • Maintain a caseload of 10-20 members with ongoing physical and behavioral health care coordination needs • Facilitate access and remove barriers to necessary care and services for members and families • Facilitate communication among members, their support systems, clinical care providers, community partners, and internal CareOregon departments, ensuring care plans are shared as appropriate • Coordinate effectively with interdisciplinary teams for integrated care plan support of complex member needs, participating in relevant team meetings • Provide appropriate support to clinical Care Coordination staff involved with members • Assist members in establishing and engaging with providers • Refer members to appropriate agencies for community support • Coordinate care for members residing outside of service area as required in contract • Assist in transition and discharge planning for members moving from acute care, long-term care, or other residential facilities back to community-based supports as directed by clinical supervisor • Take independent actions to address each member’s identified needs including (but not limited to): scheduling provider appointments, arranging for transportation, arranging for an interpreter, confirming authorizations/referrals, assisting with Health-Related Services Flex requests, verifying needed services are provided, referring to community resources and locating members • Assess for and identify physical and behavioral health care coordination needs • Identify and appropriately address risk factors and service needs that may impact member outcomes • Utilize a trauma-informed approach to provide member-centric physical and behavioral health care and support • Assist members in moving through the continuum of care based on clinical, medical, and behavioral health needs • Use motivational interviewing to coach members toward improved physical and behavioral health care behaviors and self-management • Utilize assessment information to develop individualized care plans for assigned members • Coordinate with providers to ensure integrated physical and behavioral health care plans are timely, effective, and consider the members’ unique needs • Implement physical and behavioral health care coordination plans in collaboration with the member, providers, case workers and other relevant parties • Develop working partnerships with community health care providers concerning member needs and care plans • Maintain compliance with Coordinated Care Organization (CCO) requirements • Complete initial and subsequent documentation for care coordination activities and support clinical care coordinators in plan creation adhering to required timelines • Maintain working knowledge of CareOregon Advantage (COA) and Oregon Health Plan (OHP) benefits, including Dental, Vision, Hearing, Addictions, and Mental Health benefits • Report member complaints to Appeals and Grievance team for investigation and follow-up, per protocol • Maintain compliance with the Model of Care requirements, if applicable • Participate in quality and organizational process improvement activities and teams when requested • Participate in work-related continuing education when offered or directed