Job Description

Posted Date: 12/2/2019

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 Manager of Behavioral Health, the Behavioral Health Community Health Worker (BH-CHW) is a trusted member of the community who facilities the care of high risk patients faced with behavioral health and/or substance use challenges to promote adherence to key components of their health care. The BH-CHW engages patients, creates a trusting relationship, and provides care coordination and management to patients with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. The BH-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 BH-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 and telephonic care coordination and care management to patients with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability
  • Provides care coordination and care management services to patients in the community, homes and health care settings that patients access.
  • Conducts comprehensive assessments with patients and performs clinical intervention through the development of a care management treatment plan specific to each member with high level acuity needs
  • Assesses, plans, implements, monitors and evaluates options and services to meet complex behavioral health and psychosocial health needs of patients
  • Places referrals to external behavioral health and/or substance use community based resources to assist patient in accessing quality and cost effective care (i.e. - outpatient therapy, medication management, day treatment, partial hospitalization, MAT treatment, etc.)
  • Reviews benefits options, researches community resources, trains/creates behavioral routines and enables patients to be active participants in their own healthcare
  • Coordinates care with internal and external resources to meet identified needs of the patient's care plan and collaborates with providers
  • Monitors and evaluates effectiveness of care plan and modifies plan as needed
  • Ensures patients are engaging with their PCP to complete their care management treatment plan or preventive care services
  • Acts as a liaison and advocate between the patient, family, physician and facilities/agencies
  • Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs
  • Provides clinical consultation to physicians, professional staff and other teams members/supervisors to provide optimal quality patient care and effective operations
  • Addresses barriers to follow through on health care including, but not limited to: homelessness/housing instability, financial resources, transportation, child care, etc. and places referrals to community based resources as necessary
  • 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


  • Bachelor’s Degree in Social Work, Psychology, Counseling, Rehabilitation, or other related field, required.
  • BLS Certified (CPR/First Aid)

Years of Experience:

  • Required 2 years of experience in behavioral health management and/or acute behavioral health care setting focusing on outpatient/inpatient utilization, case management and discharge planning

Work Related Experience:

  • Experience working with the needs of vulnerable populations who have chronic or complex bio-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 individuals 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 judgment and a realistic understanding of issues; able to use reason, even when dealing with emotional 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.
  • Ability to travel, including valid driver’s license and auto liability insurance coverage according to company policy.
  • 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 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 demands

Specialized Knowledge:

  • Possesses knowledge and expertise of the healthcare system and resources available in the area in which BH-CHW is providing care coordination/care management services
  • Demonstrates knowledge and understanding of the impact of the community and culture on health, illness, health practices, health beliefs, access to care and participation in treatment and services
  • Working knowledge of community based and government services and resources need to assist patients in accessing services and addressing potential Social Determinants of Health

Application Instructions

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