Integrated Health Care Specialist

CUHCC's mission is to seek health equity in our community by advancing the well-being of diverse people. The clinic is known for providing high quality care to diverse patients and is moving forward in improving timely access to care for patients. The Integrated Health Care Specialist provides care coordination within CUHCC's integrated care model, working collaboratively with patients and interdisciplinary care teams to address medical, behavioral health, substance use, and psychosocial needs.

This position supports patients with complex care needs by coordinating services, facilitating referrals, and transitions of care, addressing barriers to accessing care, and promoting continuity across CUHCC programs and external health and community-based services. The Integrated Health Care Specialist also provides screening follow-up, brief interventions, patients education, crisis support, and resource navigation within the scope of the position. Services are patient-centered, culturally responsive, trauma-informed, and grounded in harm reduction and recovery-oriented approaches.

The position serves as a resource to patients and care teams and supports CUHCCs' commitment to coordinated, accessible, and whole-person care.

This position reports to the Integrated Care Program Manager and has no direct reports.

The salary range for this position is between $24.56/hr - $28.00/hr which equates to between $51,084.80/annually - 58,240/annually for 1.0 FTE, depending on qualifications.

This position is primarily in person at the clinic, with a hybrid schedule consisting of four days on-site and one remote workday per week. The regular work schedule is Monday-Friday, 8:00am to 4:30pm. Staff are expected to be available to work on-site on their designated remote day when patient care, staffing, meetings, training, or other operational needs require an in person presence.

The remote workday and schedule may be adjusted based on clinic and program needs.

Please note, this position is not eligible for H-1B or Green Card sponsorship. This position does not offer a STEM OPT training program.

Support psycho-social and holistic screening and follow up in medical visits - 25%

• Participate in work groups related to patients' physical health, behavioral health, substance use and psychosocial screenings
• Respond to provider's requests for additional support for patients with identified behavioral health, care coordination, psychosocial, or crisis needs.
• Review and respond to positive screening results and identified patient needs in accordance with established clinic workflows and protocols
• Support warm handoffs and connections to appropriate internal or external services when needs are identified during a medical visit
• Support consistent screening and follow-up workflows by identifying gaps, barriers, or opportunities for process improvement

Provide care coordination and brief interventions for patients with identified needs - 50%

• Provide panel management and care coordination for patients with frequent emergency department utilization and other identified complex care needs
• Document care coordination activities, patient interactions, interventions, and follow-up in the electronic health record (EHR)
• Promote harm reduction strategies and the recovery model tailored to patient's needs, goals, and readiness for change
• Provide psychosocial education, skill building, behavior-change support, crisis intervention, suicidal ideation assessment, de-escalation, and goal planning
• Follow-up on emergency room visits including reviewing available discharge information, coordinating follow-up care, and addressing barriers to recommended care
• Schedule…