Social Care Navigator - Hybrid

Job DescriptionJob Description

MAJOR RESPONSIBILITIES:

• Conduct standardized screenings for Health-Related Social Needs (HRSNs) using the Unite Us screening tool.
• Provide care management services to Medicaid Managed Care members eligible for Enhanced HRSN Services.
• Coordinate access to community-based resources and services to address social determinants of health.
• Maintain accurate documentation and adhere to Medicaid and HEALI SCN program requirements.

DETAILED RESPONSIBILITES:

HRSN Screening:

• Use the Unite Us IT platform to administer the HRSN screening tool via the phone
• Screen Medicaid members annually or after major life events (e.g., hospitalization, loss of benefits, change in housing).
• Obtain member consent, verify Medicaid eligibility, and confirm enrollment in Social Care Coverage.
• Ensure screenings are conducted in a private, secure setting and assess whether follow-up care or navigation is needed.
• Educate members on the purpose and outcome of screenings and assist in identifying next steps for support.

Enhanced HRSN Services Care Management:

• Conduct Eligibility Assessments for Medicaid Managed Care members via the phone to determine qualification for Enhanced HRSN Services.
• Develop and manage individualized Social Care Plans, tracking referrals and outcomes in Unite Us.
• Coordinate services across multiple domains, including but not limited to transportation, utility assistance, home safety modifications, temporary housing, and cooking supply delivery.
• Collaborate with in house EOC program and external providers to ensure service delivery within designated timelines.
• Conduct follow-up with members to assess satisfaction, service impact, and need for additional referrals.
• Document all case notes, outreach attempts, and service updates according to HEALI SCN guidelines.

QUALIFICATIONS:

• Demonstrated understanding of social determinants of health and experience addressing the needs of underserved populations.
• Proficient in using case management platforms; familiarity with Unite Us is a plus.
• Strong communication and interpersonal skills to build trust and rapport with clients.
• Ability to work independently with minimal supervision, manage time effectively, and adapt to evolving program guidelines.
• Capable of handling sensitive information with discretion and maintaining client confidentiality.
• Committed to trauma-informed, person-centered care practices.

• Required Valid New York Driver's License and Insured Vehicle
• PPD Required before start date

EDUCATION/TRAINING/EXPERIENCE:

• High school diploma
• Minimum of 2 years of experience in care coordination, case management, social services, or a related setting.
• Prior experience working with Medicaid populations or community-based health programs .
• Bilingual in English and Spanish
• Completion of HEALI SCN training(s) required upon hire

CATEGORY:

• NON-EXEMPT