Social Care Navigator

Primary Duties & Essential Functions

• Manage incoming referrals for enhanced HRSC services.
• Engage Medicaid members in person, telephonically, or virtually to discuss referrals and assist in managing referrals.
• Confirm eligibility for services using Epaces.
• Cook up referrals with the individuals and document the status of referrals.
• Provide longitudinal care management for Members receiving enhanced HRSN services.
• Conduct and document outreach to community members.
• Manage Member consent and attestation throughout the screening, assessment, and care management process.
• Conduct HRSN screening using the Accountable Health Communities (AHC) screening tool.
• Determine Member eligibility for enhanced HRSN services and refer to eligible programs and services.
• Create and oversee social care plans.
• Ensure referrals are acted upon by HRSN service providers within required timeframes and redirect as necessary.
• Document progress notes and action taken with each referral.
• Update the social care plan during service provision.
• Maintain eligibility status changes in collaboration with the Social Care Screener and Assistant Director of Care Management.
• Confirm service delivery completion and support the transition to additional resources.
• Use data and data tools to report referral patterns and trends to the management team.
• Share feedback on successes and challenges with the Assistant Director of Care Management.
• Participate in quality assurance, data validation, and utilization monitoring activities.
• Support internal reviews, corrective action plans, and external monitoring or audit requests.
• Maintain confidentiality and comply with HIPAA, Medicaid, and DOH data privacy and security requirements.
• Attend required training related to DOH guidance, waiver updates, reporting requirements, and program compliance.
• Participate in supervision, team meetings, and case conferences as required.
• Perform other duties as assigned in support of DOH and 1115 Waiver program objectives.
• Meet billables weekly to ensure program viability (minimum 5 screenings and assessments daily).

Required Education, Knowledge, And Skills

• Minimum of associate’s degree in human services, public health, social work, or related field; bachelor's degree preferred.
• Experience in case coordination, care navigation, outreach, or direct service provision with Medicaid or underserved populations.
• Knowledge of SDOH/HRSN concepts and community-based service systems.
• Ability to follow standardized protocols for screening, assessing, referring, documentation, and follow-up.
• Demonstrated ability to maintain accurate, timely, and compliant records.
• Proficiency with electronic health records and/or DOH-aligned reporting systems.
• Strong organizational, communication, and interpersonal skills.
• Adherence to DOH guidance, Medicaid regulations, and 1115 Waiver service requirements is mandatory.
• Knowledge and understanding of health equity, social drivers of health, and social care data.
• Excellent communication and presentation skills.
• Experience using translation services is preferred.
• Ability to build collaborative working relationships.
• Ability to use various technology platforms.
• Effectively work in a hybrid work environment.
• Some local travel may be required.
• Willingness to respond to the needs of a culturally diverse population.
• Ability to be seated and use computer equipment for several hours a day.

Abilities And Working Conditions

• Detail-oriented and capable of multitasking.
• Proficient computer skills and willingness to learn additional software applications.
• Demonstrated ability to thrive in a demanding environment.
• Must have a valid NYS driver’s license with a clean MVR.
• Preferred experience in supporting individuals with disabilities.
• Willingness to respond to the needs of a culturally diverse population.
• Ability to be seated and use computer equipment for several hours a day.