Health Integration Liaison

AgeSpan•Lawrence, MA

4d•$28 - $30

About The Position

AgeSpan is seeking a Health Integration Liaison to build and maintain collaborative relationships between AgeSpan, Tufts Medicine Integrated Network (TMIN), Greater Lawrence Family Health Center, and other clinical partners. The role supports improved health outcomes and coordinated care for members by facilitating communication across health plan teams, AgeSpan staff, clinical partners, and community-based services. The liaison maintains accurate documentation of GUIDE-related interactions in the CCS system, facilitates referrals to community resources, monitors follow-up and access barriers, and works closely with AgeSpan care management staff on individualized care planning. The position also participates in case conferences and partnership meetings, supports improvements to referral and information-sharing workflows, and ensures compliance with agency policies and applicable laws, regulations, and contractual requirements. This position is 37.5 hours per week. AgeSpan offers flexible scheduling and hybrid work opportunities depending on role and hours. The pay range is $28.00–$30.00 per hour.

Requirements

Bachelor's degree in social work, human services, or a related field.
An associate degree combined with significant relevant professional experience may be considered in lieu of a portion of the educational requirement.
Ability to maintain accurate, timely, and thorough documentation.
Excellent written, verbal, and interpersonal communication skills, including the ability to build and maintain effective relationships with providers, community partners, members, caregivers, and internal teams.
Ability to work independently and as part of an interdisciplinary team across organizations and disciplines.
Strong organizational, analytical, and problem-solving skills, including the ability to identify service barriers, coordinate solutions, prioritize demands, and follow through.
Ability to work respectfully and effectively with people from diverse cultural, socioeconomic, and life experiences using a person-centered approach.
Ability to manage multiple responsibilities, meet deadlines, maintain confidentiality, and complete timely follow-up in a dynamic collaborative environment.

Nice To Haves

Experience in case management, care coordination, or working with older adults.
Familiarity with case management systems, electronic recordkeeping platforms, and other computer-based applications.

Responsibilities

Serve as the primary liaison between AgeSpan and TMIN, Greater Lawrence Family Health Center, and other clinical partners.
Facilitate communication and collaboration among health plan teams, AgeSpan staff, and clinical partners to support coordinated care and information sharing.
Document GUIDE-related interactions, referrals, communications, and follow-up activities accurately and promptly in the CCS system.
Connect health plan members with appropriate community-based services and resources, including supports addressing health-related social needs.
Monitor referrals and follow-up to help ensure timely connections, identify access barriers, and address outstanding needs.
Collaborate with AgeSpan care management staff on member services and individualized care planning, including complex needs, referrals, service transitions, care gaps, and barriers to access.
Participate in meetings, case conferences, and care coordination discussions with internal teams and external partners.
Identify opportunities to improve referral workflows, information sharing, and integration between health care providers and community-based services.
Comply with AgeSpan policies and procedures and applicable state and federal laws, regulations, contractual requirements, confidentiality rules, and information-sharing standards.