Social Care Navigator I (Bilingual-Spanish)

Social Care Navigator I (SCN)

The SCN is the front line of NYREACH’s Social Care Network, connecting Medicaid members to the social care services they need to thrive.

• Conduct proactive outreach to Medicaid members telephonically, in person, and in community settings to engage them in social care services.
• Administer HRSN screenings to identify unmet social needs across domains including housing stability, food insecurity, transportation, and interpersonal safety.
• Assess and document member eligibility for enhanced HRSN services in accordance with Social Care Network protocols.
• Build rapport and trust with members, meeting them where they are and applying a person-centered, trauma-informed approach.
• Connect members with appropriate community resources, including social service agencies, community-based organizations, healthcare providers, and government benefit programs.
• Facilitate referrals to social care services, track each referral through to completion, and follow up with members and providers to confirm needs were addressed (closed-loop referral management).
• Provide ongoing navigation support to members with complex or multiple needs, escalating and re-referring as circumstances change.
• Collaborate with team members, partner-based navigators/CHWs, and community partners to coordinate care for members with complex needs and ensure seamless service delivery.

Documentation & Community Partnership:

• Use technology platforms to document member eligibility, outreach activities, case notes, referral outcomes, and other required data, adhering to established protocols and confidentiality standards.
• Maintain accurate, timely records of all interactions, referrals, and outcomes.
• Represent NYREACH at community events and cultivate working relationships with community organizations, partners, and healthcare facilities to strengthen the local resource network.

Nutrition Focus:

• Manage a caseload of assigned members with nutrition-related needs, connecting them to healthy food resources such as food pantries, benefits programs, medically tailored meals, and nutrition services.
• Conduct workshops, seminars, one-on-one consultations, and presentations on healthy eating habits, disease prevention, and nutrition topics.
• Provide personalized nutrition education to individuals and groups, focusing on healthy eating habits, meal planning, portion control, food preparation, and the impact of nutrition on overall health.

Required Qualifications

• Bachelor’s degree in social work, human services, public health, community health, nutrition, or a related field.
• Experience in social services, community health, care navigation, or a related field; familiarity with community resources and benefit programs.
• Strong communication, interpersonal, and organizational skills; effective verbal and written communication is essential for interacting with members, providers, and other stakeholders.
• Cultural sensitivity and the ability to adapt to different needs and work with a diverse population.
• Comfort using technology platforms for screening, referrals, and documentation.
• Bilingual Spanish required.

PREFERRED QUALIFICATIONS

• Background in nutrition, dietetics, or community nutrition.
• Experience with HRSN screening, closed-loop referral platforms, or Medicaid populations.
• Community Health Worker (CHW) training or lived experience in the communities served.

Work Environment

• Onsite, full-time position (Monday-Friday).
• Open to one weekend day a month.
• Flexible setting that includes in-office work, community events, community organizations and partners, healthcare facilities, etc.
• Direct work with members in person, over the phone, and through other communication methods.

About the Role

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.

Responsibilities

Conduct proactive outreach to Medicaid members telephonically, in person, and in community settings to engage them in social care services.

Administer HRSN screenings to identify unmet social needs across domains including housing stability, food insecurity, transportation, and interpersonal safety.

Assess and document member eligibility for enhanced HRSN services in accordance with Social Care Network protocols.

Build rapport and trust with members, meeting them where they are and applying a person-centered, trauma-informed approach.

Connect members with appropriate community resources, including social service agencies, community-based organizations, healthcare providers, and government benefit programs.

Facilitate referrals to social care services, track each referral through to completion, and follow up with members and providers to confirm needs were addressed (closed-loop referral management).

Provide ongoing navigation support to members with complex or multiple needs, escalating and re-referring as circumstances change.

Collaborate with team members, partner-based navigators/CHWs, and community partners to coordinate care for members with complex needs and ensure seamless service delivery.

Use technology platforms to document member eligibility, outreach activities, case notes, referral outcomes, and other required data, adhering to established protocols and confidentiality standards.

Maintain accurate, timely records of all interactions, referrals, and outcomes.

Represent NYREACH at community events and cultivate working relationships with community organizations, partners, and healthcare facilities to strengthen the local resource network.

Qualifications

• Bachelor’s degree in social work, human services, public health, community health, nutrition, or a related field.
• Experience in social services, community health, care navigation, or a related field; familiarity with community resources and benefit programs.
• Strong communication, interpersonal, and organizational skills; effective verbal and written communication is essential for interacting with members, providers, and other stakeholders.
• Cultural sensitivity and the ability to adapt to different needs and work with a diverse population.
• Comfort using technology platforms for screening, referrals, and documentation.
• Bilingual Spanish required.

Skills

• Strong communication, interpersonal, and organizational skills.
• Effective verbal and written communication.
• Cultural sensitivity and the ability to adapt to different needs and work with a diverse population.
• Comfort using technology platforms for screening, referrals, and documentation.

Benefits

Essen Health Care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.

Pay

Competitive salary commensurate with experience.

Schedule

Full-time position (Monday-Friday).