Integration Specialist (BA)

The Integration Specialist provides Health Home services and similar supports for patients whose complex medical, behavioral health and social concerns impede their ability for self-care. The Integration Specialist is a member of the patient-centered inter-disciplinary Care Management team, with a strong understanding of chronic conditions and how each condition can compound another, leading to poor health outcomes. The Integration Specialist meets with patients in the location of their choice, including homes, the community, in-patient settings, or clinics. Through motivational interviewing and other techniques, the Integration Specialist works with the patient to create a Health Action Plan and follows up regularly to evaluate progress. Sea Mar is a community-based organization founded in 1978, specializing in service to Latinos in Washington State, operating more than 90 medical, dental, and behavioral health clinics.

Responsibilities

Provides Health Home services and similar supports for patients with complex medical, behavioral health and social concerns; Conducts mandatory and optional screenings to identify care needs; Creates a health action plan (HAP) with the patient including long-term goal, short-term goals, and actionable steps; Provides six core Health Home services: health promotion, support to patient/family, care coordination, comprehensive transitional care, referral to social and community resources, and care management; Monitors patients in person or by phone for changes in symptoms, life circumstances, and medication side effects; Uses motivational interviewing to help patients achieve HAP goals; Reviews health action plan and screenings with patient and/or family every four months; Maintains communication with patient's care team and ensures medical providers are aware of staff working with the client; Participates in case reviews and multidisciplinary meetings; Consults with behavioral health providers; Coordinates with community providers and case managers; Documents all calls, visits, and encounters per policy; Maintains appointment reconciliation in scheduling database; Carries a caseload of up to 60 patients as assigned by Care Manager; Provides up to two contacts per month for high-intensity patients; Other duties as assigned

Requirements

BSW or BA/BS in Human Services, Health Sciences or related field with experience in social service case management or care coordination; Ability to understand medical terminology pertaining to chronic conditions; Ability to work with an interdisciplinary care team; Must be able to perform independently and as an interdisciplinary team member; Must be able/willing to work with translators if not bilingual; Must have or obtain CPR certification within initial probationary period; Must have good organizational and communication skills; Ability to work effectively with all persons and groups with respect and awareness of cultural differences; No history or evidence of alcohol or other drug misuse for three years prior to employment and no misuse while employed; No felony conviction within the last seven years and never convicted of assault, abuse, fraud, or crimes causing harm to another; Valid driver license, proof of auto insurance, and a vehicle safe for daily use; Driver's abstract required prior to hire; Typing proficiency of at least 45 wpm; Working knowledge of Microsoft Office; Ability to learn and use electronic health record programs; Must complete agency and State mandatory trainings; Must maintain up-to-date vaccination record; Must complete pre-hire and annual TB test screening; Annual employee health screening required; Annual influenza vaccine required unless approved exemption; Must obtain Basic Life Support (BLS) CPR within 90 days of hire and maintain it; 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 knowledge of community resources; Ability to read and interpret procedure manuals and write routine reports; Ability to compute rate, ratio, and percent; Ability to solve practical problems with concrete variables

Nice to have

Bilingual English/Spanish; Master's level preferred for Integration Specialists in collaborative roles

Benefits

Medical; Dental; Vision; Prescription coverage; Life Insurance; Long Term Disability; EAP (Employee Assistance Program); Paid time off starting at 24 days per year; 10 paid holidays; 401(k)/Retirement options; Opportunity for advancement; Full-time employees working 30 hours or more are eligible for the benefit package