Location: Local Hybrid: Local to the McMinnville, OR area, with flexibility to work both remotely and/or in-person at YCCO's office in McMinnville.

Department:            Health Plan Operations                                                              FLSA Status:                             Exempt

Division:                   Community Health                                                                      Physical Strength:                   Light (L)

Reports To:              Community Health Systems & Tribal Relations Manager         Location:                                   Local Hybrid

Supervisory                                                                                                                   Occasional Weekend 

Role:                         No                                                                                                Work:                                          Yes   

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

The Social Needs Program Specialist expands, maintains, and monitors capacity for social needs services and supports eligible Yamhill Community Care (YCCO) members, by working with various vendors, community-based organizations, and providers of targeted resources and services offering nutrition, housing, and other social supports. This position also works extensively with internal teams including Care Management (CM) and Utilization Management (UM). This position requires extensive knowledge of resources within the community and an understanding of barriers that impact individuals and families in YCCO communities, which may prevent them from accessing and/or obtaining the resources they need for stability. This role will be frequently collocated or onsite with partner organizations (4 or more times per month). 

Essential Duties

1. Develops strategies and policies for partnership with community and provider organizations to create a social needs provider network that can meet the social needs of all eligible members.
2. Builds and maintains a consistent and reliable network of providers.
3. Manages strong relationships with providers and vendors in order to support coordination with internal CM program and staff and addresses barriers concerning benefit delivery. 
4. Leads collaborative work within and across teams that may include, but is not limited to, other program Specialists, Community Health Workers, CM Case Managers, Nurse Case Managers, Community Providers, Health Services Supervisor, Traditional Health Worker Liaison.

Job Duties

Community Resource Development

• Interprets Oregon Health Authority (OHA) contract and state and federal regulations, incentive metric requirements, Health Equity Plan, and other plan-related documents to maintain compliance with social needs benefit and service delivery requirements.
• Develops strategic engagement and relations plan for YCCO’s partnership with community-based organizations and local and state service providers and vendors.
• Creates and informs policies and procedures regarding the provision of the health-related services benefit and services and the social needs provider network.
• Manages the compilation and inventory of resources available throughout the YCCO region and surrounding counties to meet the health-related social needs of members, including food, housing, and climate supports.
• Develops and maintains cross-agency partnerships and relationships that will support YCCO’s social needs.
• Delivers OHA and internally required reports and documentation related to Heath Related Social Needs services resources and services.  

Provider Network Management

• Recruits, supports, and provides technical assistance for contracted social needs providers to maintain reporting and provider agreement compliance.
• Manages conflicts, barriers, issues or concerns between vendors / service providers and members or CM staff.
• Develops new and support existing resources within the community to build and maintain YCCO’s social needs screening and support network.
• Serves as a liaison, in coordination with Provider Relations, between internal CCO (Community Care Organization) staff and external partners to facilitate collaboration and maintain positive community relations.
• Support with any partnerships between YCCO and Tribal or Urban Indian Health Program entities, including contract oversight and issue resolution as appropriate.

Social Needs Program Leadership

• Engages with OHA around related social needs and benefit meetings, work sessions, and activities to ensure new information is incorporated in program processes.
• Develops and maintain social needs capacity assessment at least annually, with analysis of available local social needs organizations and capacity to meet regional member needs.
• Serve as main liaison for Community Information Exchange implementation internally and with community partners.
• Directs social needs screening implementation practices with community partners, social needs providers, and support with social needs integration and reporting efforts community-wide.   
• Represent YCCO at OHA and state meetings as appropriate.
• Leads collaborative work within and across teams that may include, but is not limited to, other Program Specialists, Community Health Workers, CM Case Managers, Nurse Case Managers, Community Providers, Health Services Supervisor, Traditional Health Worker Liaison.
• Develops workflows, Standard Operating Procedures, and process improvement plans to guide social needs benefit and health related services review, authorization, service delivery, and monitoring.
• Acts as an individual contributor to other CCO initiatives, Quality Assurance and Compliance activities, and assists with data reviews and processes.
• Champions health equity and YCCO efforts to redistribute power and resources; recognizes, reconciles, and rectifies historical and contemporary injustices within the YCCO healthcare and social service systems. 

Social Needs Focus Areas Climate Devices, Nutrition & Housing Services

• Maintains a current understanding of local resources and services.
• Develops and maintains positive relationships and working agreements with CCO, local vendors, and services providers.
• Works with contracts department to create MOUs or agreements to establish services and devices (if necessary).
• Works with Finance to determine inventory and supply demand in case of climate emergency.
• Serves as a liaison, and/or supports CCO liaison efforts, between vendors, service providers and members during conflicts / issues with a goal of preventing the loss of partnerships and/or contracts.
• Identifies gaps in resources and services and identify solutions to address these gaps.
• Prepares social needs related reports.
• Regularly attends YCCO’s Community Advisory Council meetings to coordinate social needs screening and program processes with Children’s Health Insurance Program (CHIP) related programs and interventions.
• Other tasks as assigned.

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.
• Attends in person Annual Company Conference in Oregon; typically held in the fourth week of September.
• 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.
• Respectfully takes direction from Supervisor.
• Performs other duties as assigned.

Knowledge, Skills, & Abilities

• Knowledge of social determinant of health and their relationship to a person’s overall well-being.
• Ability to communicate effectively both orally and in writing.
• Ability to prepare clear and concise reports.
• Ability to build relationships and network with individuals at all levels, both internal and external to the organization.
• Ability to work in an environment with diverse individuals, open-minded and non-judgmental including working with those who may hold different values / experiences, such as cultural needs, language, economic status, life experience, etc.
• Ability to learn and apply policies, regulations, requirements, and rules.
• Exhibits strong organizational and record keeping skills including the ability to handle multiple priorities and demands in a dynamic work environment.
• 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 (cross-department) or shared resources across departments work model with a spirit of cooperation.
• 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 and groups.
• 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 responsibility.

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 accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

• Bachelor’s degree in Community Health, Communications, Public Health, Social Work, Public Administration, or related field,
• Two (2) years of experience in Program Coordination, Planning, and Development of Community Resources.

     OR:

• Any combination of education and experience that would qualify candidate for the position.

Preferred:

• Bilingual Skills (English / Spanish, Skills Pay available).
• Systems experience with Medicaid population.
• Experience working with affordable housing programs.

Certificates, Licenses and/or Registrations

This position does not require any certificates, licenses, or registrations. 

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.