Job Description

The Social Care Navigator supports Medicaid members by identifying unmet health-related social needs - housing, food, and transportation to address Health Related Social Needs (HSRN), determine eligibility for enhanced services under the NYS 1115 Medicaid Waiver, and provide person-centered navigation to community and clinical resources. The role strengthens the connection between healthcare and social care systems by coordinating referrals, reducing barriers, and ensuring continuity of support.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

· Conduct standardized social care screenings to identify needs related to housing, food access, transportation, safety, and other social determinants of health.

· Complete eligibility assessments to determine whether members qualify for enhanced waiver services through the regional Social Care Network.

· Provide navigation and care coordination, including warm hand-offs, follow-up, and ongoing support based on screening results and member goals.

· Engage members by phone, in person, or via secure video to build rapport, understand needs, and support access to services.

· Identify barriers related to health, housing, food insecurity, transportation, or other social needs and connect members to appropriate community-based resources.

· Document screenings, referrals, interactions, and outcomes in designated platforms such as Channels360. Unite Us

· Collaborate with healthcare providers, community-based organizations, and Social Care Networks to ensure coordinated care and continuity of services.

· Participate in regional meetings, trainings, and quality improvement initiatives related to 1115 Waiver implementation.

· Adhere to organizational standards, guidelines and health care laws and regulations.

· Maintain confidentiality and HIPAA

Requirements

· Experience in case management, care coordination, community resource navigation, or related social service roles.

· Ability to work independently, stay organized, and adapt to changing priorities.

· Effective communication skills and ability to build rapport with diverse populations.

· Computer literacy and willingness to learn referral platforms such as Channels360, Unite Us.

· High school diploma with relevant experience, or an associate degree.

· Escalate clinical issues to Nurse or Social Work Case Manager.

· Attend ongoing training and courses to keep abreast of new developments in health care.

· Adheres to organizational standards, guidelines and health care laws and regulations.

· Maintains confidentiality and HIPAA

PREFERRED SKILLS:

· Bilingual or multilingual fluency: Mandarin/Cantonese, Spanish

· Bachelor’s in Social Work, Human Services, Public Health, Psychology, or related fields.

This is a grant funded position.