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:nnSea Mar is a mandatory COVID-19 and flu vaccine organizationnnTransition of Care LPN - Posting #27130nnHourly Rate: $31.63nnPosition Summary:nnJoin a team that is focused on providing assistance to patients who are discharged from the hospital and learning how to be safe and healthy! Sea Mar is seeking Transition of Care LPN in Bellingham, WA. This full-time position will be working with the care management and transition of care teams.nnThe Transition of Care LPN delivers specific time-limited services to identified patients designed to ensure health care continuity, avoid preventable poor 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.nnThis position provides advocacy and education for the patient and/or caregiver during transitional periods between hospitals and/or other facilities and the patient’s home. The LPN collaborates with staff in hospitals and care facilities and with Sea Mar providers to resolve gaps in care, improve clinical outcomes related to Plan all cause readmission, utilization of hospital services, patient engagement after inpatient discharge and medication reconciliation post discharge. Candidates with case management experience as well as knowledge of community resources are highly preferred.nnThe Transitions of Care LPN provides support with a focus on the following areas:nnMedication self-management: Patient is knowledgeable about medications and has a medication management system.nnPatient-centered record: Patient understands and uses a personal health record to facilitate communication and ensure continuity of care.nnPrimary care and specialist follow up: Patient schedules and completes follow up visit with the primary care physician and/or specialist and is prepared to be an active participant in those interactions.nnKnowledge of Red Flags: Patient is knowledgeable about indicators that suggest their condition is worsening and how to respond.nnThis is a specialized position insofar as the LPN will have a background working with patients in various settings (such as with hospice, home health, and acute care hospitals), and will have an understanding of patients with diverse medical, mental health, and social determinant of health challenges. Interventions with patients is time and scope limited, and RNs will not maintain an ongoing caseload. However, the RNs are expected to complete outreach and transition of care activities for all patients identified and willing to participate in the program. Active participation is expected in community-wide efforts/coalitions to provide ever-improving comprehensive interdisciplinary care. Additional responsibilities and information are found on job description.nnEducation and/or Experience:nnLPN with social service experience: (home health, hospice, long-term care, case management, care coordination, wellness coaching, etc.).nnCCM or CCTM certification preferred.nnExperience working with underserved, transient populations.nnExperience working with substance use disorders, chronic mental illness, and chronic health conditions.nnExperience working with community agencies and has strong knowledge of community resources.nnExperience with motivational interviewing, the teach-back method, or patient counseling and education preferred.nnExperience in case management and care coordination.nnAttention to detail and enthusiastic problem solver.nnActive LPN License with WA State Department of Health.nnTyping proficiency of at least 45 wpm.nnBilingual (Spanish/English) preferred.nnWhat We Offer:nnSea Mar offers talented and motivated people the opportunity to work in a dynamic and growing community health organization. Working at Sea Mar Community Health Centers is more than just a job, it’s a fulfilling career with opportunity for advancement. The fringe benefits surpass most companies. For example, Full-time employees working 30 hours more, receive an excellent benefit package of:nnMedicalnnDentalnnVisionnnPrescription coveragennLife InsurancennLong Term DisabilitynnEAP (Employee Assistance Program)nnPaid-time-off starting at 24 days per year + 10 paid Holidays.nnWe also offer 401(k)/Retirement options and an exciting opportunity to work in a culturally diverse environment.nnHow to Apply:nnTo 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, Care Transition Program Manager, at Mar is an Equal Opportunity EmployernnPosted 11/21/2024nnExternal candidates considered after 11/26/2024nnThis position is represented by Office and Professional Employees International Union (OPEIU).nnPlease visit our website to learn more about us at You may also apply thru our Career page at by JazzHR