Resource Integration Specialist

The Resource Integration Specialist will work to serve the comprehensive needs of the patients of Klamath Health Partnership, Inc. (KHP) as an integral member of the Medical, Behavioral and Patient Resource teams. The Specialist will work collaboratively to administer appropriate assessments based upon the SBIRT model and refer patients to the appropriate professionals, including medical providers, medical assistants, nurses, mental health providers and community services. The Specialist works in collaboration with patient care teams to capture information that may identify barriers to health experienced by the patients of Klamath Health Partnership (KHP), in order to help with decreasing health inequities and increasing access to supportive services available within the organization and community.

The Specialist will enhance behavioral health integration coordination and ensure professional and effective delivery of integrated health care. The position will provide advice and counsel to the KHP Medical Director, Behavioral Health Director and other care teams.

The focus of the Resource Integration Specialist role will be to administer the SBIRT follow-up assessments to patients, document results in the EMR, facilitate referrals and ensure follow-up with all behavioral health referrals and appointment outcomes. The ideal candidate for this position will have the ability to connect respectfully with patients and carry out responsibilities within the mission of the KHP. The Resource Specialist will ensure all functions of assessments and referrals are done in accordance with KHP policies, practices, and procedures.

Key Responsibilities

Patient Care

• Responsible for performing the necessary functions of the integrated care position including screening, brief intervention, and referral to treatment in accordance with scope of practice guidelines, employee licenses and certifications, protocols, and standing orders.
• Consult with medical providers and behavioral health team regarding the level of care needed for all medical patients screened.
• Assist in brief intervention for medical patients in brief appointments or in the context of medical appointments.
• Be available to complete Columbia-Suicide Severity Rating Scale (C-SSRS) screening tool(s), for any patient reporting suicidal ideation to medical providers or medical team members.
• Complete referrals to behavioral health team and track response to referrals.
• Facilitate appropriate screenings of all medical patients 18 years old and older in the areas of depression, anxiety, substance abuse, and domestic violence.
• Facilitate screenings annually during a wellness visit or preventive care visit.
• Follow up with all patients referred for ongoing behavioral health care while patients are waiting on a wait list, to ensure continuity of care, including completing Columbia-Suicide Severity Rating Scale (C-SSRS) screening tool(s), or other appropriate screening tools.

Patient Records and Data Collection

• Ensure all patient records, charts and all related documentation is maintained current and consistent with best practices, in accordance with KHP policies and within all relevant laws and regulations.
• Responsible for documentation and coding of patient care; records all interactions and scoring or screenings.
• Maintains patient information and confidentiality in accordance with applicable laws and KHP policies.
• Facilitate and coordinate data collection efforts in conjunction with QA, Patient Resources and Management.

Care Coordination and Integration

• Collaborate with medical and behavioral health providers to develop, implement, audit and modify procedures for screening, assessment, brief intervention, and referral to treatment.
• Determines eligibility and completes the application process for patients eligible to receive services from Health-Related Service Needs (HRSN) programs.
• Partners with the Community Health Worker (CHW) team to coordinate resources available for Social Determinants of Health (SDOH) needs.
• Work collaboratively with onsite behavioral health to manage the needs of patients.
• Collaborate with QA, providers, and Patient Resources in monthly administrative meetings to facilitate the ongoing mission of integration of health services.

Clinical Quality Performance

• Assists in the compilation of statistical data and patient outcomes for KHP needs, as requested.
• Participates in KHP quality performance programs.
• Helps to maintain safe and clean patient care environment.
• Participates in continuing professional development to keep informed of clinical practices and assimilates this knowledge into clinical practice.
• Assists with the development and updates needed for the organizational SDOH workflow.
• Works with the Data team to ensure accurate SBIRT and SDOH screening data is captured within the EHR, per quality measure specifications, and is reportable.
• Remains up-to-date on Oregon Health Authority (OHA), Patient-Centered Primary Care Home (PCPCH), and Uniform Data System (UDS) recommendations and requirements related to SDOH.

Other

• Performs other duties as assigned.
• Comply with all applicable laws, including but not limited to medical records laws, HIPAA, billing and coding laws, OSHA and the corporate compliance program of KHP
• May Assist with transportation services and/or the scheduling of transport for KHP patients.
• Helps to Develop and maintain SDOH resources to provide current information regarding assistance available for identified barriers.
• May attend meetings/training with OHA as requested.

Desired Skills:

• Demonstrated significant knowledge of models of behavioral and primary integrated care and SBIRT model.
• Demonstrated strengths of personal integrity and self-confidence.
• Excellent written and verbal communication skills.
• Experience working in a medical setting preferred.
• Experience working with electronic health records preferred.
• Ability to empathize and connect with patients.
• Bi-lingual: Spanish-speaking preferred.
• Accessibility and mobility normally associated with practice of behavioral health.

Required Credentials:

• CADC I (including registered CADC Intern).

Preferred Credentials:

• CADC II
• Qualified Mental Health Associate (QMHA)

Accommodations

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to walk, talk, bend, lift, carry, write, and hear. The employee frequently is required to stand, walk, sit and use hands to finger, handle or feel. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.