Job Description

Location: Steward Health Care Network
Posted Date: 2/14/2020

Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

Position Purpose:

Under the direction of the program Social Worker, the Community Health Worker is a trusted member of the multi-disciplinary care management team who facilities the care of individuals with Substance Use Disorders (SUD) and Social Determinants of Health (SDOH) needs post Emergency Department discharge to promote adherence to key components of their health care. The community health worker engages patients, creates a trusting relationship, assists patients in navigating the health care system, makes patient visits in the home, community, Emergency Department, hospital or other settings, sets health goals and closely communicates with providers and care team members.

  • Provides community health worker services to high-risk patients that have Substance Use Disorders (SUD) and Social Determinants of Health (SDOH) needs
  • Initiates face to face contact with high-risk patients in the Emergency Department, hospital, community, or home (via EMS visit and/or standalone visit) and conducts telephonic outreach on an as needed basis
  • Reviews eligibility screening, psychosocial assessment and patient centered care plan developed by the Social Worker and adheres to treatment recommendations of the SW
  • Works with the patient, family/caregiver provider and other care team members such as Physician, Social Worker, community-based NP/PA, MAT Provider, as appropriate, local EMS, PCP, BH Providers, etc. to set goals for patient’s care, identify any barriers to care, and motivate patients to achieve those goals
  • Teaches key educational messages in person and over the phone and utilizes teach back methods to measure and ensure patients understanding
  • Clearly documents all activities in the patient record
  • Records and monitors the participants’ progress toward goals within specific timeframes
  • Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions
  • Helps patients fill out applications, for example for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
  • Provides advocacy, patient education and support in accessing community-based and hospital-based programs
  • Refers to internal or external services when appropriate
  • Maintain regular communication with the patient
  • Demonstrates cultural sensitivity and respect for the patient
  • Visits the patients in hospital and ED, as necessary to facilitate with transitions of care
  • Prepares reports and documents as needed or requested
  • Follows standards of work and consistently maintains department established caseloads and timeframes for case completion. Participates in the refinement and development of new standards of work
  • Meets regularly 1:1 with the Director of Behavioral Health to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations
  • Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network’s safety reporting guidelines
  • Performs all job functions in compliance with applicable federal, state, local and company policies and procedures
  • Performs other duties as assigned
  • Ability to travel to attend meetings with patients, PCPs and other members of the care team
  • Attend staff meetings and education offerings both in person and via teleconference as required
  • CHW is considered a resource expert in the assigned community/region

Education / Experience / Other Requirements


  • High school diploma required. Bachelor’s degree preferred

Years of Experience:

  • Minimum of 3 years healthcare, public health, or community-based experience

Specialized Knowledge:

  • Current unrestricted Driver’s License
  • MS Office Suite
  • Possess basic knowledge of healthcare system and resources available in their geographical region
  • Experience working with disadvantaged populations, SU populations and those impacted by social service needs
  • Understanding of language, culture and socioeconomic circumstances and desire to work with diverse populations.
  • Knowledge of the impact of culture on health, illness, health practices, health beliefs, access to care and participation in treatment and services. Demonstrated oral and written communication skills and is comfortable working with individuals from cultural and linguistically different backgrounds who face barriers in obtaining care and support services
  • Ability to serve on a multi-disciplinary care team and update team members on important clinical important and/or barriers to patient reaching health care goals
  • Understanding of how to advocate and work with patients so that he/she is in the best position to determine what they want and need, promoting the persons’ right and capacity to make decisions themselves as well as encouraging and teaching patient self-confidence that will enable them to become self-advocates
  • Knowledge of key principles of working with patients with disabilities – self-determination, self-advocacy and person/ family-centered individual planning that allow persons with disabilities to live in the safest and least restrictive community-based setting
  • Understanding and respect for disability culture and barriers that prevent individuals from receiving appropriate and quality care. Dependable and responsible. Open minded, committed and respectful of our members with chronic/complex illness and or disabilities
  • Highly motivated and capable of self-directed
  • Outstanding interpersonal skills of foremost importance to interact with families and patients.
  • Exceptional organizational skills; ability to multi-task and work independently and as part of a team
  • Demonstrated ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands
  • Ability to utilize tools for the effective documentation of the care management process

Equal Opportunity Employer Minorities/Women/Veterans/Disabled

Application Instructions

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