Integration Specialist (BA)

Sea Mar Community Health Centers•Lacey, WA

About The Position

Sea Mar Community Health Centers is recruiting an Integration Specialist to provide Health Home services and related support to patients whose complex medical, behavioral health, and social concerns affect their ability to care for themselves. The Integration Specialist is part of an interdisciplinary, patient-centered Care Management team and applies knowledge of chronic conditions and how they can interact to affect health outcomes. The specialist meets with patients at locations of their choice, including homes, community settings, inpatient settings, and clinics. They conduct screenings, make appropriate referrals, and work with patients to create and monitor a Health Action Plan (HAP) with long- and short-term goals and actionable steps. Using motivational interviewing and other techniques, they support patients in managing chronic conditions and coordinate care with patients, families, caregivers, providers, and community resources. The position delivers the six Health Home core services: health promotion, patient and family support, care coordination, comprehensive transitional care, referral to social and community resources, and care management. The specialist documents contacts and outcomes, participates in multidisciplinary care planning, and provides information and recommendations to the patient's care team. The position works in on-site and off-site settings and does not require work outside Sea Mar's traditional Monday–Friday, 8:00 a.m.–5:00 p.m. operating hours.

Requirements

Bachelor of Social Work (BSW) or bachelor's degree in Human Services, Health Sciences, or a related field, plus experience in social-service case management or care coordination; other bachelor's-level applicants may be considered with approval from contractors and/or state certification entities.
Applicants without the specified degree may be considered with two years of related experience, subject to approval from contractors and/or state certification entities.
Ability to work respectfully and effectively with people and groups while recognizing cultural differences.
Good organizational and communication skills, professionalism, and appropriate boundaries.
Ability to work in client homes, community settings, and clinics.
Ability to understand medical terminology related to chronic conditions.
Ability to work with an interdisciplinary team and to work independently while remaining an effective and professional team member.
Willingness and ability to work with translators if not bilingual.
Must obtain CPR certification during the initial probationary period; must obtain Basic Life Support (BLS) CPR within 90 days of hire and maintain current certification throughout employment.
Must complete agency and state-mandated training and, when contractually required, complete Washington State Health Homes Care Coordinator certification training within 60 days of hire; must acquire and maintain state Health Homes Care Coordinator certification.
Experience working with underserved or 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.
Typing proficiency of at least 45 words per minute; demonstrable computer skills, ability to learn applications with minimal supervision, working knowledge of Microsoft Office, and ability to learn and proficiently use electronic health record programs.
Ability to read and interpret safety rules, instructions, and procedure manuals; write routine reports and correspondence; and communicate effectively with patients, families, and colleagues.
Ability to perform basic arithmetic and calculate rates, ratios, and percentages and interpret bar graphs.
Ability to solve practical problems and interpret written, oral, diagrammed, or scheduled instructions.
No history or evidence of alcohol or other drug misuse for the three years before employment, and no such misuse while employed.
Must not have a felony conviction within the last seven years or any conviction for assault, abuse, fraud, or crimes that financially, emotionally, or physically harmed another person.
Valid driver's license, proof of auto insurance, and a vehicle safe for daily use; must submit a driver abstract before hire and may be asked to provide an updated abstract during employment.
Must maintain an up-to-date vaccination record and complete pre-hire and annual TB screening, annual employee health screening, and annual influenza vaccination. Approved medical or religious exemptions from the influenza vaccine require wearing a mask throughout flu season.

Nice To Haves

Bilingual English/Spanish.

Responsibilities

Review patient screenings and electronic records before developing a Health Action Plan; consult with other service providers as appropriate to coordinate support and avoid duplicative efforts.
Discuss treatment options and preferences with patients, families, caregivers, and providers, with consent, and coordinate the initiation of the Health Action Plan and ongoing care.
Conduct mandatory screenings and optional screenings when indicated by diagnoses or patient history.
Develop a Health Action Plan with the patient that includes a long-term goal, short-term goals, and actionable steps.
Provide the six Health Home core services: health promotion, patient and family support, care coordination, comprehensive transitional care, referral to social and community resources, and care management.
Regularly monitor patients in person or by phone for changes in symptoms, circumstances affecting self-care, and medication side effects; encourage or assist them in communicating relevant information to providers.
Use motivational interviewing and other techniques to support patients in achieving Health Action Plan goals and strengthening chronic-condition self-management.
Review the Health Action Plan and screenings with the patient and/or family every four months.
Maintain communication with the patient's care team, support clients during provider visits as requested, and ensure medical providers know which staff are working with the client.
Participate in case reviews and multidisciplinary meetings; collaborate with Care Management RNs, master's-level Integration Specialists, Care Managers, and other team members on strategies for complex clients.
Consult behavioral health providers when working with patients who have behavioral health diagnoses and are seeing a therapist.
Coordinate with community providers and case managers on the patient's behalf when needs are identified.
Document calls, visits, collateral contacts, and encounters daily according to organizational policies; gather and monitor outcome measurements.
Maintain appointment reconciliation in the scheduling database.
Carry a caseload of up to 60 patients as assigned by the Care Manager; provide up to two monthly contacts for high-intensity patients, with step-down to telephone contact when the patient demonstrates stability.
Perform other duties as assigned.