Care Manager, Social Determinants of Health (SDOH)
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 Manager, Social Determinants of Health (SDOH), the Care Manager, (SDOH – CM) is a trusted member of the Care Management team who facilities the care of high-risk patients faced with social determinant and behavioral health challenges to promote adherence to key components of their health care. The SDOH CM engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH challenges who have high rates of emergency department and inpatient utilization and/or significant financial vulnerability. The SDOH - CM 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 or telephonic clinical care coordination and care management to patients with social determinant and behavioral health challenges who have high rates of Emergency Department and/or Inpatient utilization and/or severe psychosocial vulnerability
- Provides clinical care coordination and care management services to patients in the community, and health care settings that patients access
- Provides clinical consultation to physicians, professional staff, and other teams members/supervisors to provide optimal quality patient care and effective operations
- Conducts comprehensive care needs 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 psychosocial health needs of patients
- Addresses barriers to follow through on health care including, but not limited to homelessness/housing instability, financial resources, transportation, childcare, etc. and places referrals to community-based resources as necessary
- Places 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, Child Behavioral Health Initiative Services, etc.)
- Reviews benefit 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 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
- Master’s Degree in Social Work, Psychology, Counseling, Rehabilitation, or another related field, preferred.
- BLS Certified (CPR/First Aid)
- LCSW or
- LMHC/ LICSW eligible
Years of Experience:
- At least two years of experience in social services care management and/or social services care setting focusing on outpatient/inpatient utilization, case management and discharge planning
- 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- SDOH 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
This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.
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.
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:
- Any COVID-19 related care takes place in designated areas away from other patients and their families.
- A stringent cleaning policy has been implemented throughout our facilities.
- 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.