Health Integration Liaison

AgeSpan; Lawrence (MA); Hybrid; USD 39,000 - 41,000; Full time

Benefits offered by this job

Healthcare (medical, dental)

403b Retirement Plan with agency match

20 Vacation Days

12 Sick Days

12 Paid Holidays

Social Work Licensing Program

License Renewal Paid by agency for RN\

RN's and Social Workers

Job summary

AgeSpan is seeking a Health Integration Liaison in Lawrence, MA to strengthen care coordination between health care providers, community partners, and AgeSpan members. You will facilitate referrals, maintain documentation, and support efficient care transitions in a collaborative, mission-driven team.

Hours are 37.5 per week with a pay range of $28.00–$30.00 per hour. The role emphasizes patient-centered care, compliance with policies, and opportunities for professional growth within a diverse

Qualifications

• Bachelor's degree in social work, Human Services, or a related field required.
• Demonstrated ability to maintain accurate, timely, and thorough documentation.
• Excellent written, verbal, and interpersonal communication skills.
• Ability to work independently and within an interdisciplinary team.
• Strong organizational, analytical, and problem-solving skills.
• Experience working with diverse populations preferred.

Responsibilities

• Serve as the primary liaison between AgeSpan and clinical partners to foster strong relationships and coordinate care.
• Facilitate communication between health plan teams, AgeSpan staff, and clinical partners to promote information sharing.
• Maintain timely and accurate documentation of GUIDE-related interactions, referrals, and follow-up within the CCS system.
• Facilitate referrals and connections between members and community-based services and resources.
• Monitor referral processes and follow-up to ensure timely access and address barriers to service.

Skills

Communication skills

Interdisciplinary collaboration

Documentation skills

Education

Bachelor's degree in social work or related field

Job description

AgeSpan

About Us: Since 1974 our agency has strived towards supporting an individual's desire to make their own decisions, secure their independence and remain living independently in the community. We are proud of our employees who make this possible every day. Our agency is a thought-leader, a nationally known generator of new ideas, because it welcomes creativity, your ideas. It is an outstanding place to work stimulating, friendly, collaborative. We offer competitive salaries, generous vacation time, and an excellent work/life balance. We value diversity and encourage career growth. If you have a passion for improving the lives of the elderly community and enjoy working in a diverse team driven by its mission, you've found the right place!

At AgeSpan, you'll find a work environment that combines:

• A refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds.
• A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions.
• Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills.
• A satisfying balance between your work and personal life, including a flexible workplace, generous paid time off, and wellness programs.

Depending on your role and your hours, we offer

• Flexible schedule and hybrid work opportunities
• Competitive salaries
• Healthcare (medical, dental)
• 403b Retirement Plan with agency match
• 20 Vacation Days, 12 Sick Days, and 12 Paid Holidays
• Social Work Licensing Program
• License Renewal Paid by agency for RN's and Social Workers
• And MORE!

Position Responsibility: The Health Integration Liaison serves as a key connection between AgeSpan, health care providers, and community partners to strengthen care coordination and improve health outcomes for members. This position facilitates communication, coordinates referrals to community-based services, and collaborates with internal and external teams to ensure members are connected to appropriate resources and supports. The Health Integration Liaison also monitors referral activities, maintains accurate documentation, and identifies opportunities to improve processes and strengthen partnerships between health care and community-based services.

Essential Functions:

Serve as the primary liaison between AgeSpan and Tufts Medicine Integrated Network (TMIN), Greater Lawrence Family Health Center, and other clinical partners to foster strong, collaborative relationships that support improved health outcomes and enhanced coordination of care for members.

Facilitate communication and collaboration between health plan teams, AgeSpan staff, and clinical partners to promote information sharing, align care coordination efforts, and support a coordinated approach to meeting members' needs.

Maintain timely and accurate documentation of all GUIDE-related interactions, referrals, communications, and follow-up activities within the CCS system, ensuring records are complete and up to date.

Facilitate referrals and connections between health plan members and appropriate community-based services and resources, including supports that address health-related social needs and promote overall well-being.

Monitor referral processes and follow-up activities to help ensure members are connected to appropriate services in a timely manner, barriers to access are identified, and outstanding needs are addressed.

Collaborate closely with AgeSpan care management staff to coordinate member services, share relevant information, and support individualized care planning. Activities may include discussing complex member needs, coordinating referrals and service transitions, identifying gaps in care or community supports, resolving barriers to service access, and facilitating communication among providers and internal teams to promote continuity of care.

Participate in regular meetings, case conferences, and care coordination discussions with internal teams and external partners to review member needs, address service delivery challenges, strengthen communication, and identify opportunities to improve partnership effectiveness.

Support ongoing partnership development and process improvement by identifying opportunities to streamline referral workflows, enhance information sharing, and strengthen integration between health care providers and community-based services.

Maintain compliance with all applicable AgeSpan policies and procedures, as well as relevant state and federal laws, regulations, and contractual requirements, including applicable confidentiality and information-sharing standards.

Qualifications:

• Bachelor's degree in social work, Human Services, or a related field required. Experience in case management, care coordination, or working with older adults is preferred. An associate degree combined with significant relevant professional experience may be considered in lieu of a portion of the educational requirement.
• Demonstrated ability to maintain accurate, timely, and thorough documentation. Familiarity with case management systems, electronic recordkeeping platforms, and other computer-based applications is preferred.
• Excellent written, verbal, and interpersonal communication skills, with the ability to establish and maintain effective working relationships with health care providers, community partners, members, caregivers, and internal teams.
• Ability to work effectively both independently and as part of an interdisciplinary team, coordinating efforts across multiple organizations and disciplines to support member needs and promote continuity of care.
• Strong organizational, analytical, and problem‑solving skills, with the ability to identify barriers to services, coordinate solutions, prioritize competing demands, and follow through on outstanding needs.
• Demonstrated ability to work respectfully and effectively with individuals from diverse cultural, socioeconomic, and life experiences, using a person-centered approach that recognizes individual preferences, needs, and strengths.
• Ability to manage multiple responsibilities, meet deadlines, maintain confidentiality, and ensure timely follow-up and completion of assigned tasks in a dynamic, collaborative environment.

Hours: 37.5 hours per week

At AgeSpan, we carefully consider a wide range of factors when determining rate of pay. Actual rate of pay depends on factors including but not limited to internal equity, experience, and qualifications. The pay range for this position is $28.00 - $30.00/hour.

Our Commitment to Diversity and Inclusion

AgeSpan is strongly committed to fostering a professional environment that recognizes, respects, and encourages the unique contributions of a broad spectrum of qualified employees. It is important that our employees reflect the diverse communities we serve. We maintain a work atmosphere that allows people of varied backgrounds to grow professionally and contribute to our mission by promoting diversity, equity, inclusion, and work‑life balance.