Integrated Specialist

Sea Mar Community Health Centers Sea Mar Community Health Centers, a Federally Qualified Health Center (FQHC) founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State. Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services. Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services. Sea Mar is a mandatory COVID-19 and flu vaccine organization. Position Summary The Transitions of Care (TOC) Integration Specialist delivers specific time-limited services to identified patients designed to ensure health care continuity, avoid preventable negative outcomes among at‑risk populations, and promote the safe and timely transfer of patients from one level of care to another. This position provides advocacy and education for the patient and/or their family or caregiver during transitional periods between hospitals and other facilities and the patient’s home. The TOC Integration Specialist collaborates with hospital staff, discharge planners, and care facilities to assist Sea Mar providers to resolve gaps in care, improve clinical outcomes related to the discharge plan, prevent all‑cause readmissions, and over‑utilisation of hospital services. Key Areas of Focus Medication self‑management: the TOC RN will act as a resource to the Integration Specialist as needed for medication reconciliation. Patient‑centered record: patient understands and uses a personal health record, MyChart, to facilitate communication and ensure continuity of care. Primary care and specialist follow‑up: the TOC Integration Specialist will have an understanding of patients with diverse medical, mental health, and social determinant of health challenges. The Integration Specialist will have knowledge of Red Flags and interventions with patients, which are time and scope limited. Unique, Specialized Responsibilities The TOC Integration Specialist will intensively case‑manage the patient for 30 days post‑discharge. The TOC Integration Specialist will be required to use a nationally standardised evidence‑based tool for documenting, tracking, care‑planning, and quality metric reporting. The TOC Integration Specialist will perform risk assessment for clients to identify level of need. The TOC Integration Specialist will perform root cause analysis for all readmissions to personalise interventions and support. The TOC Integration Specialist will be responsible for monthly data gathering pertaining to appointment benchmarks, risk assessment stratification, readmissions, root cause analysis, barriers to care, and access to appointments. This data will be broken down by CMS identified diagnoses. Additional skills include knowledge of CMS guidelines and standards for transitions of care, quality metric data gathering, and evidence‑based practice standards for transitions of care such as The Coleman Model. Core Responsibilities Support for patient self‑management by enhancing health literacy, assessing baseline comprehension, values, and goals, and engaging family/caregivers to be active participants in the patient’s care. Advocate and negotiate to secure appropriate patient services, support and empower patients to make informed decisions, and navigate the healthcare system to access appropriate care. Build strong relationships with providers and discharge planners to maximise patient outcomes during periods of transition. Patient and family/caregiver education: assess readiness to learn, learning styles, and use the teach‑back method for care interventions. Cross‑setting communication and collaboration between primary care and specialty/acute/rehabilitation care. Coaching and counselling of patients and family/caregivers regarding community resources, preparation for “Ask Me Three”, and recognising red flags for complications. Use of the case management process to develop care plans, provide medication reconciliation with assistance of the TOC RNs, and use evidence‑based practice for interventions. Use of population health management tools to track and monitor selected population characteristics and provide evidence‑based practice interventions for selected health populations. Use of teamwork and interdisciplinary collaboration, open communication, and shared decision‑making with stakeholders. Patient‑centered care planning to include motivational interviewing and other techniques to elicit patient’s health care goals and priorities, individualise care plan to transcend barriers and enhance patient outcomes. Productivity Standards Conduct outreach to all patients appropriate for TOC Services within two business days post‑discharge from hospital. Complete one discharge call to the patient within 48 business hours (or two attempts). Complete at least three attempts to contact all patients appropriate for TOC Services within eight business days post‑discharge. Provide at least one weekly contact/attempt to each patient for the 3 weeks following (30 days). Successful contacts include patient contacts, family/caregiver contacts, patient’s Sea Mar care team, and hospital contacts. A successful contact means the TOC Integration Specialist has spoken directly and communicated information. Document all activities performed within 24 hours. Files are audited regularly to ensure compliance with Sea Mar and TOC policy. Complete monthly reports detailing caseloads, statistics, and outcomes. Qualifications Ability to work effectively with all persons and groups with respect and awareness of cultural differences. Good organisational and communication skills. Demonstrate professionalism and appropriate boundaries in all interactions. No history or evidence of alcohol or other drug misuse for a period of three years prior to employment, and no misuse while employed. No conviction of a felony within the last seven years or of assault, abuse, fraud, or crimes that brought harm to another financially, emotionally, or physically. Position Requirements Connect and maintain effective relationships and professional rapport with patients and other members of the care team. Act professionally in patient’s home, community, or clinic setting. Navigate different systems related to managing patient care transition needs. Understand medical terminology pertaining to chronic conditions. Work with an interdisciplinary care team including medical providers, nursing staff, care coordinators, behavioural health and support staff. Perform independently and as an effective and professional interdisciplinary team member. Complete documentation in a timely and thorough manner. Language Skills Bilingual Spanish/English preferred. Read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Write routine reports and correspondence. Speak effectively before patients or employees of the organisation. Computer Skills Typing proficiency of at least 45 words per minute. Demonstrable computer skills and ability to learn applications from manuals and webinars with minimal supervision. Working knowledge of Microsoft Office. Ability to learn and use programs used for electronic health records. Mathematical Skills Calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Apply concepts of basic algebra and geometry. Reasoning Ability Apply critical‑thinking skills to carry out instructions furnished in written, oral or diagram form. Deal with problems involving several concrete variables in standardised situations. Education, Certificates, Licences, Registrations, and Medical Screening BSW or BA/BS in Human Services, Health Sciences or related field with experience in social service case management or care coordination. Experience working with underserved, transient populations. Experience working with substance use disorders, chronic mental illness, and chronic health conditions. Experience working with community agencies and strong knowledge of community resources. Experience with motivational interviewing, the teach‑back method, or patient counselling and education preferred. Additional Requirements Pre‑hire and annual health screening required. Annual influenza vaccine required, except for employees with a medical or religious exemption approved by Administration. Fully vaccinated for COVID and provide documentation or an approved exemption as a condition of hire. Obtain CPR certification within the initial probationary period and maintain certification throughout employment. Hold a valid driver’s licence and proof of auto insurance. Work Environment The TOC Integration Specialist will work in a variety of settings (on‑site and off‑site) to meet with patients and clients. Work situations and conversations will vary based on the individuals with whom the position works during the day. The position may work off‑site to complete required duties and responsibilities. The position will interact with other Sea Mar employees, members of the community, and representative community agencies on a day‑to‑day basis. The position does not require working outside traditional Sea Mar operating hours (Monday‑Friday, 8:00am‑5:00pm). Physical Requirements The physical demands include using hands for fine motor activities such as keyboarding; reaching with hands and arms; talking or hearing. Frequent standing, walking, sitting, and occasional climbing, balancing, stooping, kneeling, crouching, or crawling. Lifting up to 10 pounds frequently, and up to 50 pounds occasionally. Vision abilities required include close, distance, colour, peripheral, depth perception, and adjusting focus. What We Offer Sea Mar offers talented and motivated people the opportunity to work in a dynamic and growing community health organisation. Working at Sea Mar is more than just a job; it’s a fulfilling career with opportunity for advancement. The fringe benefits for full‑time employees working 30 hours or more include: Medical, Dental, Vision, Prescription coverage Life Insurance, Long Term Disability, EAP (Employee Assistance Program) Paid‑time‑off starting at 24 days per year plus 10 paid holidays. 401(k) / Retirement options. Exciting opportunity to work in a culturally diverse environment. Sea Mar is an equal opportunity employer. #J-18808-Ljbffr