Job Description

Location: Steward Health Care Network
Posted Date: 5/24/2023

Position Purpose:

Under the direction of Manager, Social Determinants of Health (SDOH), the Care Manager, (CM) is a trusted member of the Care Management team who facilities the care of high-risk patients faced with social determinants, to promote adherence to key components of their health care. The SDOH/Flex CM engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH, who have high rates of emergency department and inpatient utilization and/or significant SDOH-related vulnerability. They will work with the patient to set health goals and closely communicate with members of the patient’s care team. The CM provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care.

Key Responsibilities:

  • Provides face-to-face or telephonic care coordination and care management to patients with social determinant challenges who have high rates of Emergency Department and/or Inpatient 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 assessment 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 psychosocial health needs of patients
  • Addresses barriers to follow through on health care including, but not limited to: homelessness/housing instability, financial resources, transportation, etc. and places referrals to community based resources as necessary
  • Places external behavioral health community-based resources to assist patients in accessing quality and cost-effective care (i.e. - outpatient therapy, medication management, day treatment, Child Behavioral Health Initiative (CBHI) Services, etc.)
  • Review benefits options, research community resources, and enables patients to be active participants in their own healthcare
  • Coordinates care with internal and external resources to meet identified needs of patients’ 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 patient, family, physician, and facilities/agencies
  • Interacts continuously with patients, family, physician(s), and other resources to determine appropriate action needed to address needs
  • Provides clinical consultation to physicians, professional staff, and other teams’ members/supervisors to provide optimal quality patient care and effective operations
  • 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 patients


  • Bachelor’s or master’s degree in Social Work, Psychology, Counseling, Rehabilitation, or another related field, preferred.
  • BLS Certified (CPR/First Aid)

Years of Experience:

  • At least three years of experience in social services care management and/or social services care setting focusing on Social Determinants of Health, specifically housing and nutrition related needs, among adult individuals, children, and families preferred.

Specialized Knowledge:

  • Strong knowledge in Microsoft Office applications – Word, Excel, Access, PowerPoint, and SharePoint.
  • Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs
  • Experience working with disadvantaged populations, strongly 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 act 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 based on 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 within the community, 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
  • Possesses knowledge and expertise of the healthcare system and resources available in the area in which CM 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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