Health Home Integration & Care Coordinator

Sea Mar Community Health Centers; Aberdeen City; Hybrid; GBP 2,752,000 - 3,057,000; Full time

Benefits offered by this job

Medical

Dental

Vision

Life Insurance

Paid time off

Job summary

Sea Mar Community Health Centers is seeking an Integration Specialist to deliver Health Home services and care coordination. You will meet patients in homes, community sites, clinics, or other settings, initiating Health Action Plans and coordinating with internal Sea Mar services and community partners to support chronic condition management.

The role requires strong teamwork, screens for need, and follow-up with patients to monitor progress.

Qualifications

• BSW or BA/BS in Human Services or related field.
• Experience in social service case management or care coordination.
• Will obtain Health Homes Care Coordinator certification within 60 days of hire.
• Must complete CPR/BLS training within 90 days of hire.

Responsibilities

• Provide Health Home services and care coordination for patients in various settings.
• Conduct mandatory screenings and develop Health Action Plans with patients.
• Coordinate referrals to internal Sea Mar services and community resources.
• Maintain daily documentation of contacts and services in the EHR.
• Collaborate with Care Management team on complex client care strategies.
• Communicate with patients, families, and providers to support goals.

Skills

Care coordination

Case management

Interdisciplinary teamwork

Motivational interviewing

Cultural sensitivity

Bilingual English/Spanish

Education

BSW or BA/BS in Human Services

Health Home certification training within 60 days

Tools

Electronic health records

Microsoft Office

Job description

Sea Mar Community Health Centers is seeking an Integration Specialist to deliver Health Home services and care coordination. You will meet patients in homes, community sites, clinics, or other settings, initiating Health Action Plans and coordinating with internal Sea Mar services and community partners to support chronic condition management.

The role requires strong teamwork, screens for need, and follow-up with patients to monitor progress.