Embedded Care Coordinator

  • Steward Health Care System
  • Pleasant Street Fall River Massachusetts 02720 United States
  • Posted: Apr 18, 2019
Full-time Professional

Job Description

Position Purpose:  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.




Essential Duties and Primary Accountabilities: Listing of the major functions of the role including percentage of time allocated to each function.

Should include all duties required to complete the job.

% of



  • 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





Education / Experience / Other Requirements


  • 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

Physical and Mental Demands

These physical and mental demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Examples Only:

  • Must be able to effectively communicate with internal and external customers via telephone and email.
  • Able to accurately receive information through oral communication.
  • Able to accurately review data and figures both in hard copy and electronic formats.
  • Utilize a computer (including but not limited to a mouse and keyboard) and telephone intermittently throughout entire shift, for periods of up to four (4) hours at a time.
  • Able to accurately sort through data and think through issues in a time‐pressured environment.
  • Able to focus on a specific event or activity for up to four (4) hours at a time without interruption.
  • Able to maintain a calm and collected presence while addressing the concerns from an internal and external customer
  • Able to accurately learn and retain new information, knowledge and skills.
  • Able to efficiently manage multiple tasks, with varying degrees of priority, at the same time.