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.