Integrated Care Specialist/Community Health Worker

On-Site Service:

Federally Qualified Health Center

Reports To:

Division and Clinical Care Managers

The Integrated Care Specialist (ICS) is responsible for increasing access to health services by helping patients and their families navigate community services and adopt healthy behaviors. The ICS supports the medical team through an integrated approach to care management and community outreach. As a priority, activity will promote, maintain, and improve the health of patients and their families. Duties will include providing social support and informal counseling, advocating for individuals and public health needs, and providing community outreach to potential patients. The ICS is expected to have an understanding of mental illness and addiction and be willing and ready to engage with clients who struggle with these issues at all levels. The Integrated Care Specialist is responsible for collaborating with the organization’s multidisciplinary healthcare team to provide a thriving integrated system of care and must demonstrate the following personal and physical qualifications, which are essential functions of the position:

Essential Duties and Responsibilities

1. Conducts outreach and prevention education services, targeting individuals in need of a medical home and/or with chronic disease.
2. Performs comprehensive screening/assessment activities including health status, health risks and social needs factors; connects patients to relevant community resources with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing healthcare costs.
3. Assists patients in gaining access to and navigating a primary health care medical home and other community based social services (i.e. behavioral health services, housing, dental services).
4. Works in collaboration and continuous partnership with chronically ill or “high risk” patients and their families, clinic/hospital/specialty providers and staff and community resources to promote timely access to appropriate care.
5. Is responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
6. Creates and promotes adherence to the documented care plan, developed in coordination with the patient, primary care provider(s) and/or behavioral health provider(s).
7. Provides ongoing follow up, basic motivational interviewing and goal setting with patients/families.
8. Increases continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
9. Collaborates with medical, dental and behavioral health provider staff to manage overall patient health; understands the correlation between physical and behavioral health issues.
10. Counsels patients on interventions to modify behaviors associated with health risks.
11. Provides ongoing assistance to patient/family to increase their health literacy.
12. Assists patients with completing applications and registration forms.
13. Conducts eligibility determinations, enrollments and follow-up with uninsured or underinsured patients; assists with PCP designations.
14. Educates patients regarding the hospitalization process and the importance of timely outpatient follow up to reduce hospital readmissions.
15. Facilitates patient access to appropriate medical and specialty providers; assists patients in connecting with transportation resources as indicated.
16. Exhibits excellent working relationships with patients, visitors and staff, effectively communicating Central City Integrated Health’s mission.
17. Works closely with medical providers to ensure that patients have comprehensive and coordinated care. Follow up with patients should be continuous from initial identification through closure by means of phone calls, home visits and visits to other settings where patients can be found.
18. Acts as a patient advocate and liaison between the patient/family and community service agencies (i.e. schools, Department Human Services, hospitals, support groups, etc.).
19. Assures consumers rights are being maintained at all times.
20. Possesses knowledge about community resources appropriate to the needs of the target population; provides case management/resource assistance as indicated.
21. Must demonstrate an ability to remain calm and perform effectively and professionally during peak periods of activity and in crisis situations.
22. Records patient care management information in the EMR no later than 24 hours after patient contact.
23. Participates in a multidisciplinary care team and identifies problems and provides feedback to team members regarding a solution.
24. Takes part in performance improvement activities such as, quality assurance audits and Patient Centered Medical Home processes.
25. Assists with the workflow of the clinic as needed.
26. Participates in the integration of services including primary care, behavior health, dental services and supportive housing; serves as a resource to other providers and staff.
27. All other duties as assigned by supervisor.

Qualifications and Skills

• Experience working with patients exhibiting severe and persistent mental illness
• Possession of a valid Michigan Chauffeur’s Driver’s License
• Demonstrated ability to follow State of Michigan driving laws, evidenced by an insurable driving record
• Ability to work cooperatively with staff and others involved in the delivery of service to patients
• Must be comfortable with community outreach
• Experience in managing multiple tasks simultaneously and meeting critical deadlines
• Must maintain confidentiality relating to treatment in accordance with HIPAA guidelines
• Must possess knowledge of the healthcare field including medical terminology and the use of electronic health records
• Must be knowledgeable about community resources appropriate to the needs of patients/families.

• Exceptional customer service and phone etiquette
• Ability to work with a culturally and economically diverse patient population
• Ability to initiate and maintain positive working relationships with CCIH staff and other organizations
• Good communication skills, such as listening well and using language appropriately
• Ability to maintain effective and organized systems to ensure timely patient flow

Education / Experience

• Bachelor of Science Degree with 2+ years community based experience
• Successful completion of a Community Health Worker certification program (preferred)

Credentialing / licensure

Must be available to work any and all hours scheduled. These include but are not limited to early mornings, evenings and weekend hours as determined the organization and our patient population. Hours are subject to change based on need.

T. Conte Human Resources
Detroit Central City
10 Peterboro, Suite 208
Detroit, MI 48201
FAX: (313) 831-2604

Detroit Central City is an approved National Health Service Corps Site