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About the Role

The Integration Specialist provides Health Home services and similar supports for patients whose complex medical, behavioral health, and social concerns impede their ability for self-care. This role is a member of the patient-centered inter-disciplinary Care Management team, with a strong understanding of chronic conditions. The Integration Specialist meets with patients in various locations, conducts screenings, makes referrals, and develops Health Action Plans with patients to help them self-manage their chronic health conditions.

Responsibilities

Reviews screenings and electronic records prior to HAP, consulting with other service providers to best support patient goals and ensure non-duplicative efforts.
Discusses treatment options and preferences with patients, families, caregivers, and providers (with consent).
Coordinates initiation of health action plans and ongoing care coordination and management.
Conducts mandatory and optional screenings to identify care needs.
Creates a health action plan (HAP) with the patient, including long-term goals, short-term goals, and actionable steps.
Provides six core services in accordance with Health Home program requirements: health promotion, patient/family support, care coordination, comprehensive transitional care, referral to social and community resources, and care management.
Monitors patients regularly (in person or by phone) for changes in symptom severity, life circumstances impacting self-care, and medication side effects.
Encourages patients to relay information to medical providers and/or specialists, or relays it themselves when needed.
Uses motivational interviewing and other techniques to help patients achieve HAP goals.
Reviews health action plans and screenings with patients and/or families every four months.
Actively engages patients and supporters to increase chronic condition self-management behaviors.
Demonstrates knowledge and skills necessary to provide care appropriate to the age and abilities of the patients served.
Maintains active communication with members of the patient’s care team.
Supports clients during provider visits as requested.
Ensures all medical providers are aware of all staff working with the client.
Participates in case reviews and/or other multidisciplinary meetings with the client’s care team.
Collaborates with other Care Management team members to develop strategies for working with complex clients.
Consults with behavioral health providers when working with patients with behavioral health diagnoses.
Coordinates with community providers and case managers on the patient’s behalf when a need is identified.
Documents daily all telephone calls, visits, collateral contacts, and encounters according to departmental and organizational policies and procedures.
Gathers and monitors outcome measurements.
Maintains appointment reconciliation in the scheduling database.
Other duties as assigned.

Requirements

Ability to work effectively with all persons and groups with respect and an awareness of cultural differences.
Good organizational and communication skills.
Demonstrates professionalism and appropriate boundaries in all interactions.
No history or evidence of alcohol or other drug misuse for a period of three (3) years prior to the date of employment.
No misuse of alcohol or other drugs while employed.
No felony conviction within the last seven years.
No conviction of assault, abuse, fraud, or crimes that have brought harm to another financially, emotionally, or physically.
Valid driver license, proof of auto insurance, and a vehicle safe for daily use.
Must submit a driver’s abstract demonstrating safe driving record prior to hire.
Must be able to complete job responsibilities in various locations: client’s home setting, community setting, or clinic.
Ability to understand medical terminology pertaining to chronic conditions.
Ability to work with an interdisciplinary care team including medical providers, nursing staff, care coordinators, behavioral health, and support staff.
Must be able to perform independently and effectively and professionally as an interdisciplinary team member.
Able/willing to work with translators if not bilingual.
Must have or obtain CPR certification within the initial probationary period and maintain it throughout employment.
Typing proficiency of at least 45 wpm.
Demonstrable computer skills and ability to learn computer applications from manuals and webinars with minimal supervision.
Working knowledge of Microsoft Office.
Ability to learn and proficiently use programs pertaining to electronic health records.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Must maintain up-to-date vaccination record.
Must complete a pre-hire and annual TB test screening.
Annual employee health screening required.
Annual TB test required.
Annual influenza vaccine required (exception for approved medical or religious exemptions).
Employees with an approved exemption must wear a mask at all times during flu season.

Skills

Health Home services
Care Management
Chronic condition management
Screenings (functional abilities, daily medical self-management, fall risk, depression, anxiety, drug and alcohol use)
Referrals to internal and community resources
Motivational interviewing
Health Action Plan development
Care transition assistance
Community-based care coordination
Health promotion
Patient and family support
Referral to community and social support services
Comprehensive care management
Interdisciplinary team collaboration
Bilingual English/Spanish preferred
Reading and interpreting documents
Writing routine reports and correspondence
Effective communication (one-to-one with patients, families, colleagues)
Computer proficiency
Microsoft Office Suite
Electronic health records (EHR) systems
Basic Life Support (BLS) CPR certification
Experience working with underserved, transient populations
Experience working with substance use disorders, chronic mental illness, and chronic medical conditions
Experience working with community agencies
Strong knowledge of community resources

Location

On-site
Off-site
Client's home setting
Community setting
In-patient settings
Clinics

Work Type

Full-time
On-site
Off-site

Experience Level

Experience in social service case management or care coordination
Two years relatable experience (if no degree)
Experience working with underserved, transient populations
Experience working with substance use disorders, chronic mental illness, and chronic medical conditions
Experience working with community agencies

Education Level

BSW or BA/BS in Human Services, Health Sciences or related field
Consideration for other bachelor’s level applicants with similar experience
Consideration for applicants without a degree if they have two years relatable experience and necessary approvals

Salary/Compensations

27.32 USD Hourly

Benefits

Medical
Dental
Vision
Prescription coverage
Life Insurance
Long Term Disability
EAP (Employee Assistance Program)
Paid-time-off starting at 24 days per year
10 paid Holidays
401(k)/Retirement options

About the Company

Sea Mar Community Health Centers is a Federally Qualified Health Center (FQHC) founded in 1978.
It is a community-based organization committed to providing quality, comprehensive health, human, housing, educational, and cultural services to diverse communities, specializing in service to Latinos in Washington State.
Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services.
Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services.
Sea Mar is a mandatory COVID-19 and flu vaccine organization.
Sea Mar offers talented and motivated people the opportunity to work in a dynamic and growing community health organization.
Working at Sea Mar Community Health Centers is more than just a job, it’s a fulfilling career with opportunity for advancement.
The fringe benefits surpass most companies.
Offers an exciting opportunity to work in a culturally diverse environment.

Equal Opportunity

Sea Mar is an equal opportunity employer.