OHSU Health Services is committed to the ongoing journey of being an anti-racist organization that acknowledges the enduring impacts of historical injustices on health; addresses clinical, social, and structural systems and conditions that undermine health and wellness; strives to become a culturally-proficient workplace that reflects the communities served; and fosters an environment of belonging, respect, and inclusion where everyone feels empowered and safe to bring their full, authentic selves to the work. Change requires individuals at all levels of the organization to be proactive in redistributing resources and power equitably by restructuring policies, clinical and financial strategies, culturally sensitive data analysis and the way data is used. OHSU Health unequivocally expects its staff and leadership to fully support this mission in these efforts.

The Community Outreach Specialist serves as an important member of the Care Integration and Coordination multi-disciplinary team of OHSU Health Services. The Community Outreach Specialist works in partnership with the multi-disciplinary care team and member providers to directly support OHSU Health Services Members and families in addressing social determinant barriers, improving individual and community health, and in identifying new systems to improve the delivery of care from a culturally-sensitive and linguistically appropriate approach. The Community Outreach Specialist helps to facilitate community-based education and assists the multi-disciplinary care team to coordinate and provide holistic services for Members/families that will improve health outcomes, improve engagement with community resources, and empower Members to fully participate in the health care system.

1. Direct Member/Family Support and Advocacy. Responds to care team referrals and Member self-referrals for care coordination, individual and family support, health promotion, and resource system navigation from a culturally sensitive and linguistically appropriate approach; performs initial intake assessment to assist in identifying potential issues related to social determinants of health; providing face-to-face and telephonic outreach to best meet the needs of the Member. Supports Members and families with biopsychosocial needs in coordinating care with external providers and serves as a system navigator and point of contact. Assumes advocate role on Member’s behalf to ensure receipt of timely and appropriate services. Assists Members in problem solving issues related to the health care delivery, financial and social barriers. Assists Members in gaining access to community services. Collaborates with the multi-disciplinary care team to meet member/family and program goals.
2. Health, Education, Prevention and Outreach. Provides face-to-face and telephonic outreach in assisting the Member access services and resources in navigating the health care system. Involved in the development and delivery of culturally congruent and trauma informed health education classes, presentations, programs and written materials for a variety of audiences to include health care providers, community members, Members and families. Assists in development and delivery of systems and services that encourage member and family engagement and health behavior change. Innovations in this area may include community based interventions, home visits, family system intervention. May conduct home and community visits on an as-needed basis to assist Members/families with complex medical/social needs. Conducts screening and outreach to identify social determinant barriers and health risk, coordinating with the Care Integration and Coordination team in addressing needs consistent with the Member’s plan of care. May perform initial and general assessments of Members coming into the OHSU Health Services to help in determining future care integration and coordination needs and potential support resources.
3. Routinely documents all Member interactions and Member engagements in the EMR to ensure a longitudinal record is maintained of all Member interactions. Collects clinical and engagement data and enters information into the electronic medical record (EMR) and in the engagement tracking spreadsheet for tracking and metric purposes. Maintains medical record confidentiality at all times through the proper use of computer passwords, maintenance of secure files; adherence to HIPAA guidelines and policies.
4. Monitors and evaluates the services and community-based resources necessary to respond to the member’s individual health care needs. Assists in ensuring updated information is provided for OHSU Health Services Community Resource Directory.
5. Fosters positive and professional relationships and acts as a liaison with internal and external customers to ensure effective working relationships. Developing and maintaining an effective working relationship with community partners to increase successful referrals, availability of resources, and interagency innovation.
6. Utilizes proper telephone and personal etiquette and judicious use of other verbal and written communications, following OHSU and OHSU Health Services policies, procedures and guidelines. Follows OHSU and OHSU Health Services telecommuting policies and procedures as a member of the field-based staff.

• High School diploma or equivalent.
• Certification as a Traditional Healthcare Worker (THW) is required. Traditional health worker types include Doula, Peer Support Specialist (PSS), Peer Wellness Specialist (PWS), Personal Health Navigator (PHN) and Community Health Worker (CHW).
• BLS/CPR certification within six (6) weeks of hire.
• Two (2) years relevant work experience in a mission-driven organization with one of those years being work experience with underserved populations with complex medical and social needs.
• Able to travel within the tri-county area with an active and unrestricted driver’s license, reliable transportation and active automobile insurance coverage.
• Must be able to perform the essential functions of the position with or without accommodation.

• Fluency in written and spoken English. Must be able to communicate effectively verbally and in writing.
• Excellent telephone communication skills.
• Ability to work collaboratively with a multi-disciplinary team of health care providers.
• Customer service skills with the ability to interact professionally and effectively.
• Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.
• Experience in community outreach services providing health information, advocacy, social support, and assistance engaging with the health care system.
• Knowledge and experience working within Epic as the electronic medical record.
• Knowledge of adult learning and behavior change principles.
• Knowledge of community-based resources.

Working Conditions: Monday through Friday work schedule, day time hour’s variable to accommodate meeting schedules and availability to members. Position is field-based with the employee working remotely from a home-office location that meets the criteria established by OHSU for teleworking. A portion of the position may require time in the clinic practice setting and in the community setting to fulfill the essential functions of the position; interaction extensively by phone or in person with Members, providers, internal and external customers; minimal travel within the tri-county area.