Job Description

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 role of the Community Health Worker (CHW), Housing is to assist individuals and families who are experiencing homelessness or housing instability. The CHW-Housing engages patients, creates a trusting relationship, and provides care coordination and management to patients facing homelessness/housing instability who have high rates of utilization and/or severe psychosocial vulnerability. The CHW will make patient visits in the home, community, Emergency Department, hospital or other settings and works with the patient to set health goals and closely communicate with members of the patient’s care team. The CHW-Housing provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care.

  • Provides face to face care coordination services to high risk patients who are facing homelessness/housing instability.
  • Provides care coordination and care management services to patients in the community, homes, and health care settings that patients access.
  • Provides advocacy, patient education, and support in accessing community-based and hospital-based programs related to homelessness/housing instability.
  • Utilizes resources of public and private agencies and community organizations to meet the housing needs of patients and families.
  • Assists patients with additional services and supports for any health-related social needs: food insecurity, financial resources, transportation, accessing resources, clothing, legal assistance, etc.
  • Assists patients in filling out housing/shelter applications.
  • Makes referrals to case managers, as appropriate, and/or refers patient’s family to community support services and resources.
  • 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
  • Evaluates Care Needs Screening responses and makes appropriate referrals to internal care management programs or to external resources.
  • Records and monitors the participants’ progress toward goals within specific timeframes
  • Collaborates with youth and family service agencies at the local, county and state level including but not limited to schools, special education services, DCF, family court systems.
  • Works collaboratively with the member’s PCP and/or other key providers in planning and directing each patient’s treatment program
  • 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

Education / Experience / Other Requirements


  • High school diploma required, Bachelor’s degree preferred
  • BLS Certified (CPR/First Aid)

Years of Experience:

  • Required minimum 2 years of experience in behavioral health management and/or acute behavioral health care setting focusing on outpatient/inpatient utilization, case management and discharge planning

Work Related Experience:

  • Experience working with the needs of vulnerable populations who are facing homelessness/housing instability
  • Experience working with disadvantaged populations 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 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 service excellence practices demonstrated through personal behavior and work ethic.
  • 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.
  • 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

Specialized Knowledge:

  • Possesses knowledge and expertise of housing resources available in the area in which CHW-Homelessness is providing care coordination services
  • Working knowledge of government and community based resources and delivery systems needed to assist patients to address homelessness/housing instability/Social Determinants of Health.
  • Experience providing resource information and continued support to patients to ensure access to services to address homelessness/housing instability/Social Determinants of Health utilizing culturally sensitive practices.

Application Instructions

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