Location: Mount Vernon,WA, USA
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. We are recruiting for the following position:Sea Mar is a mandatory COVID-19 and flu vaccine organizationTransition of Care Integration Specialist - Posting #27118Hourly Rate: $26.52Position Summary:Sea Mar Community Health Centers is looking for a full time Transition of Care (TOC) Integration Specialist for our Care Management Department in Mount Vernon, WA. This position will work with patients and at Sea Mar clinics throughout Skagit County, travel will be required. The Integration Specialist delivers specific time-limited services to identified patients to ensure healthcare 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 and from one type of setting to another. This position provides advocacy and education for the patient and/or his family or caregiver during transitional periods between hospitals and/or other facilities and the patient's home. For this position, having case management experience, care coordination, problem-solving skills, and the ability to work independently is helpful.The TOC Integration Specialist collaborates with hospital staff, discharge planners as well as 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-utilization of hospital services.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 to navigate the healthcare system to access appropriate care.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 counseling of patients and family/caregivers regarding community resources.Use of the case management process to develop care plans, provide medication reconciliation and use evidence-based practice for interventions.Use of population health management tools to track and monitor select population characteristics and provide evidence-based practice interventions.Patient-centered care planning to include motivational interviewing and other techniques to elicit patient's health care goals and priorities.Position Requirements:Ability to connect and maintain effective relationships and professional rapport with patients and other members of the care team.Ability to act professionally in patient's home setting, community setting, or clinic.Ability to navigate different systems in relation to managing patients care transition needs.Ability to understand medical terminology pertaining to chronic conditions.Ability to work with an interdisciplinary care team.Ability to complete documentation in a timely and thorough manner.Education and/or Experience: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 populations.Experience working with substance use disorders, chronic mental illness, and chronic health conditions.Experience working with community agencies and knowledge of community resources.Experience with motivational interviewing or patient counseling and education preferred.Bilingual (Spanish/English) preferred, but not required.What We Offer:Sea Mar offers talented and motivated people the opportunity to work in a dynamic and growing community health organization. Full-time employees working 30 hours or more receive an excellent benefit package of:MedicalDentalVisionPrescription coverageLife InsuranceLong Term DisabilityEAP (Employee Assistance Program)Paid-time-off starting at 24 days per year + 10 paid Holidays.We also offer 401(k)/Retirement options and an exciting opportunity to work in a culturally diverse environment.How to Apply:To apply for this position, complete the online application and click SUBMIT or APPLY NOW. If you have any questions regarding the position, email Peggy Perry, Program Manager TOC, at ...@seamarchc.org .Sea Mar is an Equal Opportunity EmployerPosted 11/14/2024External candidates considered after 11/19/2024This position is represented by Office and Professional Employees International Union (OPEIU).Please visit our website to learn more about us at www.seamar.org .You may also apply through our Career page at .#J-18808-Ljbffr