Social Care Manager-Capital Region

About the role

At Healthy Alliance, our purpose is to improve health and empower communities facing barriers. Every community has its own needs, affecting the health of those who live, learn, work, and play within them. Our network brings together organizations, big and small, to coordinate and collaborate so that all communities have reliable access to the resources they need. Because every New Yorker deserves the same opportunity to be healthy.

Designated as the Social Care Network (SCN) Lead Entity for the Capital Region, Central NY, and North Country under New York’s 1115 Waiver Amendment’s SCN & Health-Related Social Needs (HRSN) Program, we are responsible for ensuring a seamless, consistent end-to-end process for screening, navigation, and delivery of services—including food, housing, and transportation—to thousands of Medicaid Members. This transformative program sustains our vision of a world where everyone has a fair and just opportunity to be as healthy as possible.

As a 2019‑2024 Albany Business Review’s Best Places to Work and a 2021‑2026 Modern Healthcare’s Best Places to Work in Health Care award recipient, we strive to maintain a culture where high‑performing, mission‑driven team members collectively work toward better health for all. We are dedicated to promoting a culture built upon autonomy, mastery, and purpose; we believe our differences in strengths and perspectives play an integral role in propelling us forward, while our core values ground us, serving as the common thread that unites our team.

Responsibilities

• Manage incoming referrals for enhanced HRSN care management to support successful and timely connections for community members.
• Provide longitudinal care management for Members receiving one or more enhanced HRSN services.
• Utilize the Electronic Provider Assisted Claim Entry System/Medicaid Eligibility Verification System (ePACES/MEVS) and other data sources to confirm Medicaid enrollment and HRSN screening status, as well as existing care team management.
• Conduct and document outreach to community members in alignment with required frequency, modality, and timeframe.
• Manage Member consent and attestation as required throughout the screening, assessment, and care management process.
• Conduct HRSN screening using the Accountable Health Communities (AHC) screening tool to assess Member HRSNs.
• Conduct eligibility assessments to determine Member eligibility for enhanced HRSN services and refer Members to eligible programs and services, including enhanced HRSN services and/or existing federal, state, and local resources.
• Develop Social Care Plans that include a summary of Member needs, eligibility, and services to which they are referred.
• Ensure referrals are acted upon by HRSN service providers within required timeframes and redirect referrals as necessary to support service connection.
• Document progress notes and action taken with each referral, as detailed in the Network Standards and Quality Program.
• Update the Social Care Plan throughout service provision in collaboration with the Member and service provider to reflect strategies and interventions for meeting identified HRSNs.
• Monitor and manage eligibility status changes in collaboration with Eligibility Specialists and Enhanced HRSN service providers.
• Confirm service delivery completion and Member needs have been addressed satisfactorily and support the transition to additional resources.
• Demonstrate ability to use various technology platforms to ensure successful and timely referral connections are made.
• Maintain effective communication with internal team members, community members, and partner organizations to ensure overall coordination of care.
• Collaborate with Performance team to report partner effectiveness and efficiency regarding referral response and service delivery and escalate community member service issues in a timely manner.
• Regularly use data and data tools to report referral patterns and trends to the Referral Coordination Manager.
• Share detailed feedback on successes and challenges of the role with the Referral Coordination Manager and continually look for opportunities to enhance and simplify the community member experience.
• Effectively work in a hybrid work environment. Some local travel may be required for meetings, community events, and other job