Integration Specialist (BA)

Sea Mar Community Health Centers•Everett, WA

4d•Hybrid

About The Position

Sea Mar Community Health Centers is seeking an Integration Specialist to provide Health Home services and similar supports for patients facing complex medical, behavioral health, and social challenges. As a member of a patient-centered, inter-disciplinary Care Management team, this role requires a strong understanding of chronic conditions and their compounding effects on health outcomes. The Integration Specialist will engage with patients in various settings, including their homes, the community, in-patient facilities, and clinics. Key responsibilities include conducting timely screenings, making appropriate referrals to internal and external resources, and developing Health Action Plans with patients using techniques like motivational interviewing. The role involves regular follow-up to monitor progress towards goals and providing core Health Home services such as care transition assistance, community-based care coordination, health promotion, patient and family support, and comprehensive care management. The Integration Specialist will also collaborate with the client's interdisciplinary team, providing information and recommendations regarding care.

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 employment and no misuse while employed.
No felony conviction within the last seven years or conviction of assault, abuse, fraud, or crimes causing harm to another.
Valid driver license, proof of auto insurance, and a vehicle safe for daily use.
Must submit a driver’s abstract demonstrating safe driving ability prior to hire.
Ability 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.
Ability to perform independently and effectively 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.
Bilingual English/Spanish 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 communicate effectively one-to-one with patients, families, and colleagues.
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.
BSW or BA/BS in Human Services, Health Sciences or related field with experience in social service case management or care coordination.
Alternatively, other bachelor’s level applicants with similar experience may be considered if approved by contractors and/or state certification entities.
Applicants without a degree may be considered if they have two years of relatable experience and are approved by contractors and/or state certification entities.
Must complete WA State Health Homes Care Coordinator certification training within sixty days of hire (when contractually necessary).
Must acquire and maintain state Health Homes Care Coordinator certification.
Must complete agency and State mandatory trainings.
Must obtain Basic Life Support (BLS) CPR within 90 days of hire date and maintain it throughout employment.
Experience working with underserved, transient populations.
Experience working with substance use disorders, chronic mental illness, and chronic medical conditions.
Experience working with community agencies and strong knowledge of community resources.
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 (exceptions for approved medical or religious exemptions).

Nice To Haves

Bilingual English/Spanish

Responsibilities

Reviews screenings and electronic records prior to HAP development, consulting with other service providers as appropriate to ensure coordinated and non-duplicative efforts.
Discusses treatment options and preferences with patients, families, caregivers, and providers (with consent), coordinating the initiation of health action plans and ongoing care.
Conducts mandatory and optional screenings to identify patient care needs based on diagnoses or history.
Creates a health action plan (HAP) with the patient, including long-term goals, short-term goals, and actionable steps.
Provides the six core services of the Health Home program: 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 affecting self-care, and medication side effects, encouraging patients to communicate this information to providers.
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 enhance chronic condition self-management behaviors.
Demonstrates knowledge and skills necessary to provide age-appropriate care.
Maintains active communication with members of the patient's care team and ensures all medical providers are aware of staff working with the client.
Supports clients during provider visits as requested.
Participates in case reviews and multidisciplinary meetings with the client’s care team.
Collaborates with other Care Management team members to develop strategies for complex clients.
Consults with behavioral health providers when working with patients with behavioral health diagnoses.
Coordinates with community providers and case managers on behalf of patients.
Documents all telephone calls, visits, collateral contacts, and encounters according to policies and procedures, and gathers outcome measurements.
Maintains appointment reconciliation in the scheduling database.
May carry a caseload of up to 60 patients.
Provides up to two contacts per month for high-intensity patients, with a step-down to telephone contact when stability is demonstrated.