Job Description

Location: Steward Health Care Network
Posted Date: 2/5/2020

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:

The LDN will work closely with patients to promote healthy living and behavioral change for Chronic Disease Management through population management of registry, health education, preventive care delivery, and evidence-based standards of practice. The LDN will be responsible for developing a relationship with patients and through Motivational Interviewing (MI), assist them in the process of actively managing their chronic conditions by providing support, encouragement, and education on medical nutritional therapy. The LDN will help individuals use existing skills and develop new skills to improve their health and quality of life. This position will have a focus on behavior modification for patients with Chronic Conditions such as COPD and CHF. The position reports to the Regional Director of Pharmacy and Wellness.

Key Responsibilities

  • Performs a comprehensive dietary assessment of patient nutritional status and collaborates with team members in developing a plan of care
  • Provides telephonic, small-group, or face-to-face counseling, consultation, information, and/or referral services to patients managing various chronic health conditions utilizing established protocols, procedures, and educational methodologies in an accurate and courteous manner
  • Utilizes “teach back” technique to confirm participants understanding of information shared during all interactions
  • Utilizes Motivational Interviewing techniques and excellent communication skills to evoke change and/or increase patients desire to change behavior and adopt a healthier lifestyle
  • Collaborates with the patient/family, hospital team, primary care team, specialists, SHCN Care Team and other Steward Health Care Network programs, community services, and other members of the health care team to improve quality of care and outcomes
  • Appropriately adapts telephonic counseling and education methods to accommodate the unique physical, psychosocial, cultural, and age-specific needs of each patient served
  • 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
  • Actively participates in the roster review and other collaborative care initiatives with the practice staff for data collection, health reporting outcomes, clinical audits and programmatic evaluations
  • Maintains required medical documentation for case management activities in the system’s care management module (electronic medical records), according to the standards of work
  • Follows standards of work and consistently maintains department established caseloads and timeframes for case completion
  • Participates in the refinement and development of new standards of work
  • 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

Education / Experience / Other Requirements


  • Bachelor’s degree required; Master’s degree strongly preferred
  • Registered Dietitian with the Commission on Dietetic Registration required. MA LDN preferred, ability to obtain multi-state licenses as necessary

Years of Experience:

  • 3 - 5 years’ experience in medical nutrition therapy counseling. Previous experience with telephonic counseling preferred

Specialized Knowledge:

  • Must demonstrate insight into human behavior and have the ability to communicate and interact with individuals at varying levels of skill and education preparation
  • Highly motivated and self-directed
  • Willingness to teach, learn, and be open to new and innovative ways of interacting with patients
  • Experience utilizing various motivational interviewing techniques to motivate patients
  • Skill and experience in application of stages of change theories and behavior change models and case management techniques
  • Ability to interpret medical nutrition therapy information, assess the implication of treatment and develop and implement a plan of care
  • Ability to make recommendations to effectively solve problems using judgment consistent with standards, practices, policies, and procedures
  • Ability to utilize tools for the effective documentation of the care management process
  • Ability to provide small-group nutrition programs to patients to reduce high-risk behaviors by promoting healthy behaviors
  • Meets regularly 1-1 with the Regional Director of Pharmacy and Wellness to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations
  • Ability to travel to attend chapter POD meetings, staff meetings, visit select practice sites for meetings, visit patients in the community and their home as needed

Equal Opportunity Employer Minorities/Women/Veterans/Disabled

Application Instructions

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