Social Care Navigator I — Field-Based (Bilingual Spanish)

About the organization

NYREACH (New York Research, Education and Community Health) is an independent 501(c)(3) nonprofit dedicated to advancing health equity through education, community-based programs, and direct service delivery for some of the Bronx's most vulnerable and underserved residents. For over five years, NYREACH has been a trusted resource in Bronx County. Through the New York State Social Care Network, the team conducts health-related social needs (HRSN) screenings and provides services through home-delivered meals and community programs. Every service is delivered in a culturally competent, linguistically appropriate, and disability-accessible manner, with Spanish-fluent staff embedded in the communities served. The team of full-time staff and active community volunteers — including International Medical Graduates and community health workers — partners with local clinics and community organizations to meet residents where they are.

About the role

The Social Care Navigator I (SCN) is the front line of NYREACH's Social Care Network, connecting Medicaid members to the social care services they need to thrive. The SCN conducts outreach, screens members for health-related social needs (HRSN) — including housing, food insecurity, transportation, and interpersonal safety — assesses eligibility for enhanced HRSN services, and provides hands-on navigation and closed-loop referrals to community-based resources. The SCN builds trusted relationships with members and follows each referral through to completion, ensuring members do not fall through the cracks between screening and service delivery. This position carries a special focus on nutritional health, supporting members in accessing healthy food resources and nutrition-related services. The role is full-time, non-exempt, field-based at 2021 Grand Concourse, Bronx, NY 10453, reporting to the Manager, NYREACH. Schedule is Monday–Friday, 9:00 AM–5:00 PM, with one weekend day per month possibly required. Remote or fully in-office arrangements are not available.

Responsibilities

HRSN Screening & Eligibility Assessment

• 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.

Navigation & Closed-Loop Referrals

• 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.
• Perform other tasks assigned by the Senior Director of NYREACH.

Nutrition Focus — Education & Access

• 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.

Performance Expectations

• Meet or exceed monthly HRSN screening and outreach targets as established by program leadership.
• Achieve and maintain a closed-loop referral completion rate consistent with program benchmarks, ensuring members are connected to and confirmed as having received referred services.
• Complete all required documentation within established timeframes (same-day entry required for all screenings and referrals).
• Maintain an active caseload of members with nutrition-related needs and deliver nutrition education sessions, workshops, or consultations on a consistent, ongoing basis.
• Actively represent NYREACH at community events and maintain productive, ongoing relationships with partner organizations and healthcare facilities.
• Maintain professionalism, accuracy, and member-centered communication standards in all interactions.

Requirements

• High school diploma or GED required.
• 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 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.

Qualifications

• Associate's or Bachelor's degree in social work, human services, public health, community health, nutrition, or a related field (preferred).
• Background in nutrition, dietetics, or community nutrition (preferred).
• Experience with HRSN screening, closed-loop referral platforms, or Medicaid populations (preferred).
• Community Health Worker (CHW) training or lived experience in the communities served (preferred).

Work environment

This is a full-time, field-based position requiring regular fieldwork and local travel to community events, partner organizations, healthcare facilities, and other assigned locations throughout the service area. Employees are responsible for travel between locations. Setting up for community events (e.g., tables, tents, and outreach materials) may require long periods of standing and light to moderate lifting. Direct work with members occurs in person, over the phone, and through other communication methods.