Health Integration Liaison

AgeSpan•Lawrence, MA

About The Position

The Health Integration Liaison serves as the primary connection between AgeSpan, Tufts Medicine Integrated Network (TMIN), Greater Lawrence Family Health Center, and other clinical partners. The role builds collaborative relationships and facilitates communication among health plan teams, AgeSpan staff, and clinical partners to improve health outcomes, coordinate care, and meet members’ needs. The Liaison coordinates referrals to community-based services, monitors follow-up and access barriers, and works with AgeSpan care management staff on individualized care planning and continuity of care. The role also maintains accurate documentation in the CCS system, participates in meetings and case conferences, supports partnership and workflow improvements, and follows applicable policies, laws, regulations, contractual requirements, and confidentiality standards. This position is 37.5 hours per week and pays $28.00–$30.00 per hour. AgeSpan describes its work environment as supportive, collaborative, innovative, and focused on work-life balance. Flexible scheduling and hybrid work opportunities may be available depending on role and hours.

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 and ability to establish and maintain effective working relationships with providers, community partners, members, caregivers, and internal teams.
Ability to work independently and as part of an interdisciplinary team, coordinating across organizations and disciplines.
Strong organizational, analytical, and problem-solving skills, including identifying service barriers, coordinating solutions, prioritizing demands, and following 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 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 Tufts Medicine Integrated Network (TMIN), Greater Lawrence Family Health Center, and other clinical partners.
Facilitate communication and collaboration between health plan teams, AgeSpan staff, and clinical partners to support information sharing and coordinated care.
Maintain timely, accurate, and complete documentation of GUIDE-related interactions, referrals, communications, and follow-up activities in the CCS system.
Facilitate referrals and connections to appropriate community-based services and resources, including supports addressing health-related social needs.
Monitor referral and follow-up processes, identify barriers to access, and help ensure outstanding member needs are addressed.
Collaborate with AgeSpan care management staff on member services and individualized care planning, including complex needs, referrals, transitions, gaps in care, and barriers to services.
Participate in meetings, case conferences, and care coordination discussions with internal teams and external partners.
Identify opportunities to improve partnership effectiveness, streamline referral workflows, and enhance 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.