Job Description

Location: Steward Health Care Network
Posted Date: 4/28/2021

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: This position will report directly to the Post Discharge Outreach (PDO) Team Manager and will function as a member of a team to complete all daily tasks to ensure smooth day-to-day operations. The Post Discharge Outreach Coordinator facilitates provider visits post DC, assesses the quality of care received, helps prevent readmission and refers to the necessary Ambulatory Care Management (ACM) team when appropriate. Support includes, but is not limited to, making outbound initial and follow-up phone contacts, receiving return calls, gathering pertinent patient information in a survey, and determining need for provider follow up or referral to ACM programs. Post DC Coordinator will escalate issues to the Manager as warranted. Possibility to work from home after orientation if meeting productivity standards.

  • Conduct post-discharge phone calls for targeted discharges for Steward Risk patients / or populations as assigned.
  • Ensure appropriate post-discharge provider follow-up appointments are scheduled; schedule as needed.
  • Validate post-discharge services are in place, e.g., VNA, Elder Services, etc.
  • Screen for presence of medical, behavioral health, or social determinants of health
  • Refer patient to appropriate care management programs as needed.
  • Use program knowledge to identify and assess the patient for required follow up.
  • Meet or exceed departmental targets as identified by manager
  • Escalate issues and high-risk members to manager or designee as needed to establish preventative tactics to reduce utilization, readmission, and address quality issues
  • Collaborate with ACM teams to ensure communication and pertinent information is shared with key stakeholders e.g. emailing, calls for information, internal referral notes, data gathering and researching etc.
  • Research and document communications as required in Steward’s Care Management System

Education / Experience / Other Requirements


  • Minimum High School diploma or GED required
  • College degree preferred

Years of Experience:

  • Medical terminology or basic medical knowledge preferred
  • Working in Care Management environment preferred

Specialized Knowledge:

  • Strong interpersonal skills, including patient interviewing skills
  • Experience with Electronic Medical Record strongly preferred
  • Experience with Microsoft Office (Word, Excel, etc.) preferred

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

Additional Information

Steward Health Care Network is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment – with confidence and without fear.

Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience:

  1. Any COVID-19 related care takes place in designated areas away from other patients and their families.
  2. A stringent cleaning policy has been implemented throughout our facilities.
  3. A strictly controlled visitor and masking policy is required for patient and colleague safety.

You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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