Job Description

Location: Steward Health Care Network
Posted Date: 5/10/2023

Position Purpose:

The Post Discharge Coordinator supports members in transitions of care across the continuum of care. Support includes, but is not limited to, making follow up phone contacts, gathering pertinent member information, and determining outstanding needs and referring to appropriate resources. The Post Discharge Coordinator will document in the Care Management documentation system and report / escalate issues to their supervisor as warranted.

Key Responsibilities:

  • Conduct post-discharge phone calls for targeted discharges for members.
  • Provide
  • Ensure appropriate post-discharge appointments are scheduled; escalate barriers to scheduling appointments.
  • Validate post-discharge services are in place; e.g., VNA, Elder Services, etc.
  • Utilizing an algorithm, refer patient to appropriate care management programs as needed
  • Escalates high risk members to appropriate management to establish preventative tactics to reduce readmissions
  • Collaborate with acute and post-acute staff to ensure communication and pertinent information is shared with key stakeholders e.g. faxing, emailing, calls for information, data gathering and researching etc.
  • Document communications as required in Steward’s Care Management System
  • Other duties as assigned.


  • College graduate preferred

Years of Experience:

  • 1-3 years health care experience preferred

Specialized Knowledge:

  • Working in Care Management or hospital environment preferred
  • Medical terminology preferred
  • Patient related call center acceptable
  • Strong interpersonal skills
  • Solid written and verbal communication skills
  • Strong organizational skills
  • Team oriented
  • Ability to work semi-autonomously if needed
  • Experience with Electronic Medical Record strongly preferred
  • Experience with Microsoft Office (Word, Excel, etc.) preferred

Application Instructions

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