Integration Specialist – BA

Jobtailor; Elma (WA); On-site; USD 55,000 - 75,000; Full time

Job summary

Jobtailor is seeking a Health Homes Care Coordinator to provide health home services and coordinate care for patients with complex medical and behavioral health needs. You will meet clients in homes, clinics, and community settings, conduct screenings, and develop Health Action Plans with measurable goals.

The role requires collaboration with a multidisciplinary team, documentation in EHR systems, and maintaining a caseload of up to 60 patients.

Qualifications

• BSW or BA/BS in Human Services, Health Sciences, or a related field, with experience in social-service case management or care coordination
• Other bachelor’s-level applicants may be considered with contractor/state certification approval
• Applicants without the degree may be considered with two years of relatable experience and contractor/state certification approval
• Experience working with underserved populations
• Experience with substance-use disorders, chronic mental illness, and chronic medical conditions
• Experience working with community agencies and knowledge of community resources
• Ability to work effectively with diverse persons and groups with cultural awareness
• Good organizational and communication skills, professionalism, and appropriate boundaries
• Must obtain CPR/BLS certification within the probationary period
• Must acquire and maintain state Health Homes Care Coordinator certification when contractually required

Responsibilities

• Provide Health Home services and supports to patients with complex medical, behavioral health, and social concerns
• Meet patients in homes, communities, inpatient settings, or clinics
• Conduct functional, medical self-management, fall-risk, depression, anxiety, substance-use, and other screenings
• Make referrals to internal Sea Mar providers, community resources, and emergency services
• Develop Health Action Plans with long- and short-term goals and actionable steps
• Provide health promotion, patient/family support, care coordination, transitional care, community and social-resource referrals, and comprehensive care management
• Monitor patients for symptom, circumstance, and medication changes and communicate relevant information to providers
• Review Health Action Plans and screenings with patients or families every four months
• Support chronic-condition self-management and provider visits
• Participate in case reviews and multidisciplinary care-team meetings
• Collaborate with Care Management RNs, Integration Specialists, and Care Managers
• Coordinate with behavioral-health providers, community providers, and case managers
• Document calls, visits, contacts, and encounters; gather and monitor outcome measurements
• Maintain appointment reconciliation in the scheduling database
• Manage an assigned caseload of up to 60 patients and provide up to two contacts per month for high-intensity patients
• Perform other duties as assigned

Skills

Organizational skills

Communication skills

Independence / team collaboration

Cultural awareness

Bilingual English/Spanish preferred

Typing 45 wpm

Education

BSW or BA/BS in Human Services/Health Sciences

Experience in social-service case management or care coordination

Tools

Electronic Health-Record Applications

Microsoft Office

Job description

• Provide Health Home services and supports to patients with complex medical, behavioral health, and social concerns


• Meet patients in homes, communities, inpatient settings, or clinics


• Conduct functional, medical self-management, fall-risk, depression, anxiety, substance-use, and other screenings


• Make referrals to internal Sea Mar providers, community resources, and emergency services


• Develop Health Action Plans with long- and short-term goals and actionable steps


• Provide health promotion, patient/family support, care coordination, transitional care, community and social-resource referrals, and comprehensive care management


• Monitor patients for symptom, circumstance, and medication changes and communicate relevant information to providers


• Review Health Action Plans and screenings with patients or families every four months


• Support chronic-condition self-management and provider visits


• Participate in case reviews and multidisciplinary care-team meetings


• Collaborate with Care Management RNs, Integration Specialists, and Care Managers


• Coordinate with behavioral-health providers, community providers, and case managers


• Document calls, visits, contacts, and encounters; gather and monitor outcome measurements


• Maintain appointment reconciliation in the scheduling database


• Manage an assigned caseload of up to 60 patients and provide up to two contacts per month for high-intensity patients


• Perform other duties as assigned

Requirements

• BSW or BA/BS in Human Services, Health Sciences, or a related field, with experience in social-service case management or care coordination


• Other bachelor’s-level applicants with similar experience may be considered subject to contractor/state certification approval


• Applicants without the degree may be considered with two years of relatable experience and contractor/state certification approval


• Experience working with underserved, transient populations


• Experience with substance-use disorders, chronic mental illness, and chronic medical conditions


• Experience working with community agencies and strong knowledge of community resources


• Ability to work effectively with diverse persons and groups with cultural awareness


• Good organizational and communication skills, professionalism, and appropriate boundaries


• No history or evidence of alcohol or drug misuse for three years before employment and no misuse while employed


• No felony conviction within the last seven years and no conviction for assault, abuse, fraud, or specified harmful crimes


• Valid driver’s license, auto insurance, and a vehicle safe for daily use


• Driver’s abstract must demonstrate safe driving before hire


• Ability to work in clients’ homes, community settings, and clinics


• Understanding of medical terminology related to chronic conditions


• Ability to work independently and as an interdisciplinary team member


• Ability and willingness to work with translators if not bilingual


• Must obtain CPR/BLS certification within the initial probationary period or within 90 days of hire and maintain it throughout employment


• Must complete agency and state mandatory training


• Must acquire and maintain state Health Homes Care Coordinator certification when contractually required


• Up-to-date vaccination record


• Pre-hire and annual TB screening


• Annual employee health screening


• Annual influenza vaccination, unless an approved medical or religious exemption applies; exempt employees must wear a mask during flu season


• Typing proficiency of at least 45 words per minute


• Demonstrable computer skills and ability to learn electronic health-record applications


• Working knowledge of Microsoft Office


• Ability to perform basic arithmetic and interpret rates, ratios, percentages, and graphs


• Ability to solve practical problems and interpret written, oral, diagram, or schedule-based instructions


• Bilingual English/Spanish preferred

Core Competencies

Demonstrates expertise in Health Home services, care coordination, and community resource navigation while effectively managing a diverse caseload of patients with complex medical and behavioral health needs. Proficient in developing Health Action Plans and conducting various health screenings to support chronic-condition self-management.

Highest-signal resume keywords

• BSW Or BA/BS In Human Services


• Experience In Social-Service Case Management


• Health Homes Care Coordinator Certification


• CPR/BLS Certification


• Knowledge Of Community Resources

ATS Optimization Keywords

Hard Skills

• Health Action Plan Development


• Functional Screening


• Medical Self-Management Screening


• Substance-Use Screening


• Chronic Condition Management


• Typing Proficiency Of At Least 45 Words Per Minute


• Basic Arithmetic Skills


• Electronic Health-Record Applications


• Microsoft Office Proficiency


• Outcome Measurement Monitoring

Soft Skills

• Organizational Skills


• Communication Skills


• Cultural Awareness


• Professionalism


• Ability To Work Independently

Certifications & Qualifications

• CPR/BLS Certification


• Health Homes Care Coordinator Certification

Industry Keywords

• Health Home Services


• Care Coordination


• Chronic Conditions


• Behavioral Health


• Community Agencies


• Underserved Populations


• Transitional Care


• Case Management


• Patient Support


• Diverse Populations