Job Description

Administrative/ Clerical

Steward Health Care Network

Steward Health Care Network

Req Number:

Job Details:


Under the direction of the team lead, the Community Health Worker is a trusted member of the community who facilities the care of high risk patients to promote adherence to key components of their health care. The community health worker engages patients, creates a trusting relationship, assists patients in navigating the health care system, makes patient visits in the home, community, ED, hospital or other setting, sets health goals and closely communicates with the provider and care team.


* Provides community health worker services to high risk patients that have social determinants to health care
* Initiates telephonic or face to face contact with high risk patients
* Schedules and completes initial assessment, develops a patient centric plan of care and follow up schedule within specified timeframes
* Works with the patient, family/caregiver provider and other care team members such as physician, social worker or nurse to set goals for patient's care, identify any barriers to care, and motivate patients to achieve those goals.
* Teaches key educational messages in person and over the phone and utilizes teach back methods to measure and ensure patients understanding
* Clearly documents all activities in the patient record
* Records and monitors the participants' progress toward goals within specific timeframes
* 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)
* Provides advocacy, patient education and support in accessing community-based and hospital-based programs
* Refers to internal or external services when appropriate
* Maintain regular communication with the patient
* Demonstrates cultural sensitivity and respect for the patient
* Visits the patients in hospital and ER as necessary to facilitate with transitions of care
* Prepares reports and documents as needed or requested
* Follows standards of work and consistently maintains department established caseloads and timeframes for case completion. Participates in the refinement of and development of new standards of work.
* Meets regularly 1-1 with the Manager of Ambulatory Care Management to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations.
* Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network's safety reporting guidelines.
* Performs all job functions in compliance with applicable federal, state, local and company policies and procedures.
* Performs other duties as assigned


* Possess basic knowledge of healthcare system and resources available in their geographical region
* Understanding of language, culture and socioeconomic circumstances and desire to work with diverse population.
* Knowledge of the impact of culture on health, illness, health practices, health beliefs, access to care and participation in treatment and services.
* Understanding of how to advocate and work with patients so that he/she is in the best position to determine what they want and need, promoting the persons' right and capacity to make decisions themselves as well as encouraging and teaching patient self-confidence that will enable them to become self-advocates
* Knowledge of key principles of working with patients with disabilities - self-determination, self-advocacy and person/ family centered individual planning that allow persons with disabilities to live in the safest and least restrictive community based setting.
* Understanding and respect for disability culture and barriers that prevent individuals from receiving appropriate and quality care.
* Dependable and responsible. Open minded, committed and respectful of our members with chronic/complex illness and or disabilities.
* Highly motivated and capable of self-directed
* Outstanding interpersonal skills of foremost importance to interact with families and patients.
* Exceptional organizational skills; ability to multi-task and work independently and as part of a team
* Demonstrated ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands.
* Demonstrated oral and written communication skills and is comfortable working with individuals from cultural and linguistically different backgrounds who face barriers in obtaining care and support services.
* Ability to utilize tools for the effective documentation of the care management process.
* Ability to travel to attend chapter POD meetings as necessary and to visit select practice sites for meetings with patients, PCPs and other members of the care team
* Attend staff meetings and education offerings both in person and via teleconference as required.
* Proficiency with Microsoft Office applications (i.e. MS Word, Excel, Access, Outlook) and web browsers.


I. Education: High school diploma required. Bachelor's degree preferred
II. Experience: Minimum of 3 years healthcare, public health, or community-based experience
III. Certification/Licensure: Current unrestricted Driver's License
IV. Software/Hardware: MS Office Suite
V. Other: Experience with diverse populations a plus.

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