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 Integrated Community Care Manager Social Worker (ICCM-SW) is an integral member of the multi- disciplinary Care Integration and Coordination Program. The ICCM-SW provides on-site (face-to-face) and telephonic outreach, behavioral health, disease and/or care management, care coordination, education, support and navigation to OHSU Health Services Members with the goal of supporting healthy life choices and to reduce long term effects of chronic illness. The individual in this role performs other clinically based activities to assist in the coordination of care between the member, his/her provider(s), health care facilities, and community- based health organizations. The ICCM-SW offers social work intervention and coordination of needed services to Members and/or families experiencing psychosocial adjustment difficulties associated with illness, injury, disability and related hospitalization and or health care interventions. The ICCM-SW enhances the quality of Member management by promoting continuity of care and cost effectiveness through whole person care  management, care integration, and care coordination across the continuum of health care services.

• Provides on-site (face-to-face) and telephonic outreach, disease management and/or care management, education and other clinically-based activities for OHSU Health Services Members. Provides supportive counseling to reinforce Members’ strengths and assists them in dealing with the stress and feelings of grief, fear, and anger associated with serious illness, injury, hospitalization or disability. 
• Conducts interviews and assessments with Members and/or Member families and other community resources to gather information necessary in identifying and evaluating psychosocial, cultural and financial conditions, develops plans of care and interventions, and sets goals for plans of care and behavioral modification within his/her scope of practice. 
• Collaborates with OHSU Health Member’s medical and health community- based providers (that may include the primary care provider (PCP), specialist provider, behavioral specialists, or others as may be indicated) regarding the member’s treatment and resource needs and plan of care. The frequency of contact is determined based on the member’s risk acuity ranking and clinical need. 
• Collects clinical and engagement data and enters information into the electronic medical record (EMR) for tracking and metric purposes. Routinely documents all Member interactions and member engagements in the EMR to ensure a longitudinal record is maintained of all member interactions. Maintains medical record confidentiality at all times through the proper use of computer passwords, maintenance of secure files; adherence to HIPAA guidelines and policies. 
• Monitors, evaluates and maintains knowledge of community-based resources and services necessary to respond to the Member’s individual health care needs, and assists member and family in gaining access to resources. 
• 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.

• A Master’s Social Work (MSW) required. 

• Certificate of Clinical Social Work Associate (CSWA) or Licensed Clinical Social Worker (LCSW) required for employees who practice clinical social work.

Job Related Knowledge, Skills and Abilities (Competencies):

• Clinical assessment skills, consistent with state licensure scope of practice.
• Ability to assess member psychosocial status, consistent with state licensure scope of practice requirements.
• Able to prioritize and target interventions, consistent with state licensure scope of practice requirements.
• Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
• Organizational skills with the ability to handle multiple tasks and/or projects at any one time.
• Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from different departments and/or agencies within and outside OHSU and OHSU Health Services.
• Strong telephonic communication and interviewing skills.
• Analytical and interpretation skills including departmental, utilization, financial and operations data. 
• Decision-making skills with the ability to investigate and weigh alternatives, integrate data, and select the most appropriate course of action that meets the best-interest needs of the member and provides the greatest benefit to the organization.
• Creative- and critical-thinking skills with the ability to consider new ideas that will lead to process and team improvements.
• Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.

• Health care experience preferred.
• Minimum two (2) years of clinical experience.
• Prior experience in case management.
• Knowledge and experience working within Epic as the electronic medical record.
• Knowledge of Medicare and Medicaid.
• Knowledge of adult learning and behavior change principles.
• Knowledge of community-based resources.
• Demonstrated skills in motivational and health coaching, patient advocacy, health promotion, disease prevention, patient education and resource management.
• Demonstrates knowledge of NQCA and Case Management guidelines.
• Provides care management services appropriate to the age of the member served
• neonate, infant, pediatric, adolescent, adult and geriatric patients based on the principles of growth and development and life stages.

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.

 

Benefits:

• Healthcare Options - Covered 100% for full-time employees and 88% for dependents, and $25K of term life insurance provided at no cost to the employee
  
• Two separate above market pension plans to choose from
  
• Vacation- up to 200 hours per year depending on length of service
  
• Sick Leave- up to 96 hours per year
  
• 8 paid holidays per year
  
• Substantial Tri-met and C-Tran discounts
  
• Additional Programs including: Tuition Reimbursement and Employee Assistance Program (EAP)
  

Posted 12/18/2025 3:03pm

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.