Integrated Specialist

Sea Mar Community Health Centers•Mount Vernon, WA

3d•Hybrid

About The Position

Sea Mar Community Health Centers is seeking an Integrated Specialist to deliver time-limited services to patients to ensure healthcare continuity, prevent negative outcomes for at-risk populations, and promote safe transitions between care levels. This role involves advocacy and education for patients and their families during transitions between hospitals and home, collaborating with healthcare staff to resolve care gaps, improve clinical outcomes, and prevent readmissions. The specialist will focus on medication self-management, patient use of personal health records like MyChart, and follow-up care. A key aspect of this role is understanding patients with diverse medical, mental health, and social determinant of health challenges. While not maintaining an ongoing caseload, the specialist is expected to conduct outreach and transition of care activities for all identified patients willing to participate. Active participation in community-wide efforts for interdisciplinary care is encouraged. This specialized position involves intensive case management for 30 days post-discharge, using standardized tools for documentation and reporting, performing risk assessments and root cause analyses for readmissions, and monthly data gathering on various metrics. Maintaining knowledge of electronic health records, medication reconciliation, facility processes, CMS guidelines, and evidence-based practices for transitions of care is essential.

Requirements

Ability to work effectively with all persons and groups with respect and an awareness of cultural differences.
Good organizational and communication skills.
Demonstrate 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 at the facility, and no misuse of alcohol or other drugs while employed at this facility.
Cannot be a person who has been convicted of a felony within the last seven years or ever been convicted of assault, abuse, fraud, or crimes that have brought harm to another financially, emotionally, or physically.
Ability to connect and maintain effective relationships and professional rapport with patients and other members of the care team; individual has strong communication skills.
Ability to act professionally in patient’s home setting, community setting, or clinic.
Ability to navigate different systems in relation to managing patients care transition needs.
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.
Ability to perform independently and at the same time perform effectively and professionally as an interdisciplinary team member.
Ability to complete documentation in a timely and thorough manner.
Bilingual (Spanish/English) preferred.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively before patients or employees of the organization.
Typing proficiency of at least 45 wpm.
Demonstrable computer skills and an ability to learn computer applications from manuals and webinars with minimal supervision.
Working knowledge of Microsoft Office.
Ability to learn and proficiently use programs as may pertain to use of electronic health records.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
Ability to apply concepts of basic algebra and geometry.
Ability to apply critical thinking skills to carry out instructions furnished in written, oral or diagram form.
Ability to deal with problems involving several concrete variables in standardized situations.
BSW or BA/BS in Human Services, Health Sciences or related field with experience either in social service case management, or care coordination.
Experience working with underserved, transient populations.
Experience working with substance use disorders, chronic mental illness, and chronic health conditions.
Experience working with community agencies and has strong knowledge of community resources.
Pre-hire and annual health screening required.
Annual influenza vaccine required. Only exception is for employees with a medical or religious exemption approved by Administration. Employees with an approved medical or religious exemption must wear a mask at all times during the flu season.
Must be fully vaccinated for COVID and provide documentation or an approved exemption as a condition of hire.
Will obtain CPR certification within initial probationary period and will maintain CPR certification throughout employment.
Must have a valid driver’s license and proof of auto insurance.

Nice To Haves

Experience with motivational interviewing, the teach-back method, or patient counseling and education preferred.

Responsibilities

Support patient self-management by enhancing health literacy, assessing comprehension, values, and goals, and engaging family/caregivers.
Provide education and supportive interventions to increase patient skills and confidence in managing health problems, goal setting, and problem-solving.
Advocate and negotiate to secure appropriate patient services.
Support and empower patients to make informed decisions and navigate the healthcare system.
Build strong relationships with providers and discharge planners to maximize patient outcomes during transitions.
Assess patient and family/caregiver readiness to learn, learning styles, and use the teach-back method for care interventions.
Use planned learning experiences to provide patients/families/caregivers opportunities to acquire information and skills for quality health decisions.
Facilitate cross-setting communication and collaboration between primary care and specialty/acute/rehabilitation care.
Use effective communication skills to gain and transmit information, encourage team participation, leverage electronic medical record tools, and design/implement processes for timely and successful patient transitions of care.
Coach and counsel patients and family/caregivers regarding community resources, how to be prepared for “Ask Me Three”, and how to recognize red flags for complications.
Use the case management process to develop care plans, provide medication reconciliation with the assistance of TOC RNs, and use evidence-based practice for interventions.
Use population health management tools to track and monitor select population characteristics and provide evidence-based practice interventions for select health populations.
Implement and evaluate interventions in the context of the health status, culture, and health needs of the populations of which the patient is a member.
Utilize teamwork and interdisciplinary collaboration, open communication, and shared decision making with stakeholders.
Develop patient-centered care plans, including motivational interviewing and other techniques to elicit patient’s health care goals and priorities, individualizing care plans to transcend barriers and enhance patient outcomes.
Conduct outreach to all patients appropriate for Transitions of Care Services within two business days post discharge from hospital.
Ideally, connect with the patient and discharge planner/relevant hospital team in-person in the hospital prior to discharge.
Conduct most future contacts over the phone, except where a visit to the patient at home, meeting in the office, or attending PCP appointments with them might occur.
Complete one discharge call to the patient within 48 business hours (or 2 attempts).
Complete at least three attempts to contact all patients appropriate for Transitions of Care Services within eight business days post discharge from hospital.
Contact includes speaking to a patient, their responsible party (family or caregiver), hospital, or other party (as agreed to by the patient).
Provide at least one weekly contact / contact attempt with each patient for the 3 weeks following (30 days).
Successful contacts include patient contacts, family/caregiver contacts, patient’s Sea Mar care team, and hospital contacts.
Collateral contacts throughout/as needed with other providers, and/or the patient’s family/caregivers.
Document all activities performed with patients within 24 hours.
Complete monthly reports detailing caseloads, statistics, and outcomes.