Care Coordinator, Transition of Care

At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together. Umpqua Health strongly encourages applications from candidates of color as well as veterans, aiming to foster a work environment that is linguistically and culturally diverse and inclusive. Please note that at this time, Umpqua Health does not offer visa sponsorship. At Umpqua Health, our Care Coordinator for Transition of Care serves as an indispensable advocate for our members, ensuring they receive the highest quality of care as they transition between healthcare settings. In this dynamic and impactful role, you will conduct comprehensive home visits to deeply understand each member's unique needs, health conditions, and personal circumstances. By coordinating a wide range of services—from medical appointments to community resources—you will craft personalized care plans that address every facet of their well-being. Providing compassionate support and guidance to members and their families, you will simplify the complexities of the healthcare system and become their trusted point of contact. Your Impact

• Develop and manage individualized transition of care plans in collaboration with interdisciplinary teams to meet the unique needs, preferences, and goals of patients and caregivers
• Serve as the primary point of contact for patients and families during care transitions, providing clear instructions, answering questions, and offering support throughout the process
• Coordinate and schedule follow-up appointments, tests, and procedures to ensure all necessary services are arranged for a smooth transition
• Conduct home visits and post-discharge follow-up calls to assess patient status, address concerns, and reinforce care plans
• Educate patients and their families on disease management, medication adherence, and self-care practices to promote optimal health outcomes
• Work with community resources, home health agencies, and external partners to secure necessary services and support, including addressing social determinants of health such as transportation, housing, or financial assistance
• Monitor high-risk patients closely to prevent hospital readmissions and emergency room visits, adjusting care plans as needed based on changes in patients' conditions
• Accurately document all care coordination activities in the patient’s electronic medical record (EMR) in a timely manner, ensuring compliance with federal, state, and local regulations, including HIPAA
• Participate in quality improvement initiatives aimed at enhancing transition of care processes, analyzing data related to care transitions to identify trends and contribute to performance improvement strategies
• Collaborate with internal teams such as case managers, social workers, and medical directors to support the organization's vision and mission, performing additional duties as assigned
• Adhere to ethical standards in all interactions with patients, families, and professionals, maintaining professionalism and confidentiality at all times
• Perform other duties and support deliverables as assigned by the organization to help drive our Vision, fulfill our Mission, and abide by our Organization’s Values
  
  
  

Your Credentials

• Bachelor’s degree in nursing, social work, healthcare administration, or a related field
• Minimum of 2-3 years of experience in care coordination, case management, or a related healthcare role. Experience in transitions of care is highly desirable
• Current RN, LCSW, or related professional licensure is preferred. Case Management Certification (CCM, ACM) is an advantage
• Strong knowledge of care coordination principles, hospital discharge processes, and community resources.
• Excellent communication, organizational, and problem-solving skills
• Ability to work independently and as part of a multidisciplinary team.
• Proficiency in using electronic medical records (EMR) systems and other care management software
  
  
  

Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.