Integration Specialist Transitions of Care

Sea Mar Community Health Centers•Everett, WA

16h•Hybrid

About The Position

Sea Mar Community Health Centers is seeking an Integration Specialist for Transitions of Care (TOC) to provide time-limited services to patients. The goal is to ensure healthcare continuity, prevent negative outcomes for at-risk populations, and facilitate safe transfers between care settings. This role involves patient advocacy and education during transitions from hospitals or other facilities to home. The specialist will collaborate with hospital staff, discharge planners, and care facilities to address gaps in care, improve discharge plan outcomes, reduce readmissions, and prevent overuse of hospital services. The position focuses on medication self-management, patient use of personal health records (MyChart), and primary care/specialist follow-up, as well as patient knowledge of red flags indicating worsening conditions. The specialist will work with diverse patient populations facing medical, mental health, and social determinant of health challenges, without maintaining an ongoing caseload. Intensive case management for 30 days post-discharge is required, utilizing standardized tools for documentation, tracking, care planning, and quality metric reporting. Risk assessments, root cause analysis for readmissions, and monthly data gathering on various metrics are key responsibilities. A strong understanding of electronic health records, medication reconciliation, facility transition processes, CMS guidelines, and evidence-based practices 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 and no misuse while employed.
Cannot have 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; 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.
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.
Coach and counsel patients and family/caregivers regarding community resources, 'Ask Me Three', and recognizing red flags for complications.
Use the case management process to develop care plans, provide medication reconciliation with RN assistance, 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.
Implement and evaluate interventions in the context of the health status, culture, and health needs of the populations.
Utilize teamwork and interdisciplinary collaboration, open communication, and shared decision making with stakeholders.
Engage in patient-centered care planning, including motivational interviewing, to elicit patient 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.
Ideally, connect with the patient and discharge planner/relevant hospital team in-person prior to discharge.
Conduct most future contacts over the phone, with potential for home visits, office meetings, or attending PCP appointments.
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.
Provide at least one weekly contact/contact attempt with each patient for the 3 weeks following discharge (30 days).
Document all activities performed with patients within 24 hours.
Complete monthly reports detailing caseloads, statistics, and outcomes.