Integrated Health Care Specialist

OBJECTIVE/ OVERVIEW

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.

REPORTING RELATIONSHIPS

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

SALARY RANGE

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.

TYPE OF POSITION
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.

ESSENTIAL FUNCTIONS

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

• Participate in workgroups 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 appointments, coordinate transportation, and/or provide no-show follow-up calls
• Obtain ROIs to communicate with patient's external care team and/or identified supports
• Conduct home visits, site visits, or care team consults with patient and collateral sources, as appropriate
• Participate in quality improvement efforts, care team consults, and interdisciplinary groups as assigned
  

Provide referrals for patients with psycho-social and holistic complex health needs - 15%

• Complete referrals to internal (e.g., case management, ARMHS, care coordination, DV/SA advocates, pro bono legal clinic, pharmacy) and external supports when appropriate (e.g. NA/AA, support groups, community centers, rule 25, CD treatment)
• Support transitions of care (e.g., follow-up on a referral, communicate changes to care team, introduce patient to relevant staff members)
  

Other Program and Team Responsibilities - 10%

• Attend all staff meetings, care coordination team meeting, and workgroups related to integrated care and psychosocial care coordination in the clinic
• Gather and maintain current internal and community resources necessary to support patient care, referrals, and care coordination activities
• Engage in practices consistent with CUHCC's Health Care Home and Behavioral Health Home
• Participate in speaking and/or outreach engagements as assigned.
• Participate in relevant trainings and professional development activities to maintain knowledge and skills applicable to the position
• Collaborate with interdisciplinary team members to identify opportunities to improve care coordination workflows and patient care
• Participate in speaking, education, and/or community outreach activities as assigned

*CUHCC reserves the right to change or add duties to this position consistent with the job classification.

***This position requires a negative TB test, and a Hepatitis B vaccination.

All required qualifications must be included in the application materials

REQUIRED QUALIFICATIONS

• Must meet qualifications in one of the following ways:
  BA/BS plus at least two years experience in one of the behavioral sciences or related fields including but not limited to social work, psychology, or nursing from an accredited college or university AND At least 2,000 hours of supervised experience in the delivery of services to persons with mental illness OR is fluent in the non-English language group of the ethnic groups CUHCC serves (e.g., Spanish, Somali, Pashtu, Dari, Vietnamese, and Hmong).
• OR one or more of the following:
  • Has at least 6,000 hours of supervised experience in the delivery of services to persons with mental illness;
  • Is a graduate student in one of the behavioral sciences or related fields and is formally assigned by an accredited college or university to an agency or facility for clinical training
    or
  • Holds a master's or other graduate degree in one of the behavioral sciences or related fields from an accredited college or university and has less than 4,000 hours post master's experience in the treatment of mental illness.
    

PREFERRED QUALIFICATIONS

• Bilingual and/or bicultural in one of CUHCC's dominant languages: Spanish, Somali
• Experience in managing clinical care using an electronic health record
• Experience working in a Federally Qualified Health Center (FQHC) or community health
• Knowledge of community resources, social service agencies and/or health care reform
• Experience in providing care coordination to a complex, diverse population
• Excellent verbal and written communication skills
• Ability to de-escalate mental health crisis situations
• Capacity to effectively communicate in difficult clinical situations and to motivate others
• Motivation to serve patients with mental, medical, dental, and chemical health needs
  

*CUHCC reserves the right to change or add duties to this position consistent with the job classification.

At CUHCC, we're transforming urban health care and educating the next generation of healthcare professionals.

CUHCC offers a full range of dental and mental health services that are typically not offered at a community health center, such as prosthodontic services and psychiatry. CUHCC has pharmacists, psychiatric nurse practitioners, dentists, dental hygienists, nurses, family nurse practitioners, family practice physicians, internal medicine physicians, internal medicine-pediatric physicians, licensed social workers and psychologists among other disciplines on staff.

CUHCC's interprofessional care model uses a collaborative, team-based approach to deliver education and patient care, integrating these services. Students and residents at CUHCC have the opportunity to work with other students and preceptors in other fields to best serve the complex needs of the patients. Over half of CUHCC's mental health patients also receive medical services at CUHCC, allowing CUHCC providers to work collaboratively to provide patient centered care.

As a founding member in the country's first accountable care organization (ACO) for federally qualified health centers, CUHCC is leading change in urban health and improving patient outcomes to meet the Institute for Healthcare Improvement's Triple Aim: improve the patient experience, improve patient health, and reduce the cost of patient care.

Pay Range: $24.56/hr - $28.00/hr which equates to between $51,084.80/annually - $58,240/annually for 1.0 FTE, depending on qualifications.

Time Appointment:100% Appointment

Position Type: Civil-Service & Non-Faculty Labor Represented Staff

Please visit the Office of Human Resources website for more information regarding benefit eligibility.

The University offers a comprehensive benefits package that includes:

• Competitive wages, paid holidays, and generous time off
• Continuous learning opportunities through professional training and degree-seeking programs supported by the Regents Tuition Benefit Program
• Low-cost medical, dental, and pharmacy plans
• Healthcare and dependent care flexible spending accounts
• University HSA contributions
• Disability and employer-paid life insurance
• Employee wellbeing program
• Excellent retirement plans with employer contribution
• Public Service Loan Forgiveness (PSLF) opportunity
• Financial counseling services
• Employee Assistance Program with eight sessions of counseling at no cost
• Employee Transit Pass with free or reduced rates in the Twin Cities metro area

While our salary ranges provide a framework, it is important to note that most of the
time, the initial pay may not reach the maximum of the range. This approach ensures
that compensation reflects the value and unique contributions of each candidate while
maintaining equity within our organization. As part of our commitment to fair and
equitable compensation, please be aware that the salary offered to incoming candidates
will be based on their individual credentials and experience.

Applications must be submitted online. To be considered for this position, please click the Apply button and follow the instructions. You will be given the opportunity to complete an online application for the position and attach a cover letter and resume.

Additional documents may be attached after application by accessing your "My Job Applications" page and uploading documents in the "My Cover Letters and Attachments" section.

To request an accommodation during the application process, please e-mail jobcentr@umn.edu.

The University recognizes and values the importance of diversity and inclusion in enriching the employment experience of its employees and in supporting the academic mission. The University is committed to attracting and retaining employees with varying identities and backgrounds.

The University of Minnesota provides equal access to and opportunity in its programs, facilities, and employment without regard to race, color, creed, religion, national origin, gender, age, marital status, disability, public assistance status, veteran status, sexual orientation, gender identity, or gender expression. To learn more about diversity at the U: http://diversity.umn.edu

Any offer of employment is contingent upon the successful completion of a background check. Our presumption is that prospective employees are eligible to work here. Criminal convictions do not automatically disqualify finalists from employment.

The University of Minnesota, Twin Cities (UMTC)

The University of Minnesota, Twin Cities (UMTC), is among the largest public research universities in the country, offering undergraduate, graduate, and professional students a multitude of opportunities for study and research. Located at the heart of one of the nation's most vibrant, diverse metropolitan communities, students on the campuses in Minneapolis and St. Paul benefit from extensive partnerships with world-renowned health centers, international corporations, government agencies, and arts, nonprofit, and public service organizations.

At the University of Minnesota, we are proud to be recognized by Forbes as a Best Employer for Company Culture (2026), Best Employer for Women (2023, 2025, 2026), and Best Employer by State (2022-2026). In 2026, we also received Culture Excellence & Industry Awards recognition for employee appreciation and work-life flexibility.