Job Description

Management/ Professional

Steward Health Care Network

Steward Health Care Network

Req Number:

Job Details:


The role of the Embedded Care Coordinator is to assist individuals, families, and internal teams who are experiencing difficulty adjusting to illness, disability or post-acute care. The objective of the Embedded Care Coordinator is to enable the individual and/or family to develop adequate coping skills and educate them on available resources within Steward Health Care Network (SHCN) and the community.


* Provides care coordination services to high risk patients that have social determinants to health care

* Schedules and completes initial assessment, develops a patient-centric plan of care and schedules follow-up within specified timeframes

* Initiates 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

* 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

* Makes referrals to case managers, as appropriate, and/or refers patient's family to community support services and resources.

* Utilize resources of public and private agencies and community organizations to meet the needs of patients and families.

* 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.

* Embeds within practice; builds relationship with physicians, nurses, and staff by working within the practice on a daily basis as a team member

* Proactively communicates with the practice regarding upcoming appointments for identified patients and coordinates to join appointment

* Maintains an open level of communication with treating physician and case managers in planning and directing each patient's treatment program

* Influences change within practices to build a successful embedded program (confidence, leadership, independence, etc.)

* Facilitates weekly Huddles with practice manager

* Teaches key educational messages in-person and telephonically and utilizes teach back methods to measure and ensure patients understanding

* 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



* Bachelor's Degree in Social Work, Psychology, Counseling, Rehabilitation or other related field, required

* Master's degree preferred

* BLS Certified (CPR/First Aid)

Years of Experience:

* Minimum of 2 years working within health care environment

Work Related Experience:

* Must be able to effectively communicate with adults, children and adolescents, their 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 work collaboratively with practice staff and with SHCN team(s) to ensure coordination of services and supports

* 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.

* Working knowledge of government and community based resources and delivery systems needed to assist patients to address Social Determinants of Health

* Ability to work in several databases and to comply with established documentation requirements

Specialized Knowledge:

* Working knowledge of government and community based resources and delivery systems needed to assist patients to address Social Determinants of Health

* Experience providing resource information and continued support to patients/clients to ensure access to services to address Social Determinants of Health utilizing culturally sensitive practices

Application Instructions

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