Health Home Care Coordinator (Bilingual Preferred)

Sea Mar Community Health Centers; Ocean Shores (WA); Hybrid; USD 31,000 - 44,000; Full time

Benefits offered by this job

Medical, Dental & Vision benefits

401(k) retirement plan

Paid time off + Holidays

Job summary

Sea Mar Community Health Centers is seeking an Integration Specialist to deliver Health Home services and coordinate care for patients with complex medical, behavioral health, and social needs. The role flexes across home, community, inpatient settings, and clinics, emphasizing patient-centered planning and follow-up.

The Integration Specialist collaborates with care teams to create Health Action Plans, screen for health risks, and connect patients with internal Sea Mar resources and community

Qualifications

• BSW or BA/BS in Human Services, Health Sciences or related field.
• Experience with underserved populations and care coordination is valued.
• Bilingual English/Spanish preferred.

Responsibilities

• Review screenings and coordinate with other service providers to support patient goals.
• Discuss treatment options with patient/family and initiate health action plan.
• Conduct mandatory and selective screenings to identify care needs.
• Create and monitor Health Action Plan with patient for long/short-term goals.
• Provide six Health Home services: health promotion, care coordination, referrals, and care management.
• Maintain regular contact with patient to evaluate progress and adjust plans.
• Use motivational interviewing to help patients achieve HAP goals.
• Document interactions and maintain scheduling reconciliation.

Skills

Bilingual English/Spanish

Communication

Education

BSW or BA/BS in Human Services/Health Sciences

Tools

Microsoft Office

Electronic Health Records

Job description

Sea Mar Community Health Centers is seeking an Integration Specialist to deliver Health Home services and coordinate care for patients with complex medical, behavioral health, and social needs. The role flexes across home, community, inpatient settings, and clinics, emphasizing patient-centered planning and follow-up.

The Integration Specialist collaborates with care teams to create Health Action Plans, screen for health risks, and connect patients with internal Sea Mar resources and community