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.
The role of the Social Services Community Health Worker (CHW) is to assist individuals, families, and internal teams who are impacted by Social Determinants of Health (SDOH) needs. The Social Services CHW engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH needs who have high rates of utilization and/or severe psychosocial vulnerability. The Social Services CHW will make patient visits in the home, community, Emergency Department, hospital or other settings and works with the patient to set health goals and closely communicate with members of the patients care team. The Social Services CHW provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care.
Provides face to face care coordination services to high risk patients that are impacted by Social Determinants of Health such as: food insecurity, financial resources, legal assistance, transportation, applying for disability, accessing services, application assistance, etc.
Provides care coordination and care management services to patients in the community, homes and health care settings that patients access
Provides advocacy, patient education and support in accessing community-based and hospital-based programs
Utilizes resources of public and private agencies and community organizations to meet the needs of patients and families
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
Makes referrals to case managers, as appropriate, and/or refers patient's family to community support services and resources
Schedules and completes initial assessment, develops a patient-centric plan of care and schedules follow-up within specified timeframes
Telephonic or face to face contact with high risk patients of all ages to conduct a Care Needs Screening
Evaluate Care Needs Screening responses and make appropriate referrals to internal care management programs or to external resources
Records and monitors the participants' progress toward goals within specific timeframes
Collaborate with youth and family service agencies at the local, county and state level including but not limited to schools, special education services, DCFS, family court systems.
Works collaboratively with the members PCP and/or other key providers in planning and directing each patient's treatment program
Clearly documents all activities in the patient record
Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient's family
Demonstrates cultural sensitivity and respect for the patient
Education / Experience / Other Requirements
Years of Experience:
Work Related Experience:
Experience working with the needs of vulnerable populations who have chronic or complex psychosocial needs
Experience working with disadvantaged populations, preferred
Experience in a managed care environment and case management experience, preferred
Must be able to effectively communicate, present and explain complex material with patients, family members, case managers, treating physicians and community organizations
Must possess the interpersonal skills to engage children and adolescents of varying ages and families in helping relationships
Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department
Ability to take action in solving problems while exhibiting sound judgment and a realistic understanding of issues; able to use reason, even when dealing with emotionally charged topics
Ability to remain open-minded and change opinions on the basis of information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task
Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic
Ability to travel, including valid driver's license and auto liability insurance coverage according to company policy
Must possess the ability to present and explain complex material to physicians and other providers and member populations in a professional manner
Ability to work in several databases and to comply with established documentation requirements
Exceptional organizational skills; ability to multi-task and work independently and part of a team
Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demand
New England Sinai Hospital And Rehabilitation Center