Social Care Navigator

Position Overview:

Responsible for operating within the framework of the Social Care Network, providing direct assistance to individuals to address Health-Related Social Needs (HRSN) and improve overall well-being. This role involves facilitating access to essential services such as housing, healthcare, nutrition, transportation and other community resources. The Social Care Navigator collaborates closely with program members, and relevant service providers to identify and address social determinants of health, and implement a comprehensive array of supports and services, improving health outcomes and quality of life.

Role and Responsibilities:

• Screen Medicaid/Medicaid Managed Care members using the standardized NY version of the Accountable Health Communities (AHC) screening tool to assess Member Health Related Social Needs (HRSN), and eligibility for Enhanced HRSN services.
• Utilize a closed loop referral platform, Unite Us, to refer screened individuals to either existing local/state/federal services or, if eligible, to NYHER-financed Enhanced HRSN service providers.
• Track status of referrals, providing follow-up support as needed.
• Determine if an individual has experienced a status change that results in eligibility changes for Enhanced HRSN or other services.
• Collaborate with individuals eligible for Enhanced HRSN services to establish goals, develop, implement, and assess a person-centered, Social Care Plan.
• Document in Unite Us the individuals’ progress in achieving the goals and desired outcomes outlined in their unique Social Care Plan.
• Amend the Social Care Plan throughout services, ensuring information remains current and accurate, supplying information that may be helpful to support service coordination by health and social care professionals.
• Serve as a single point of contact for the individual and work with related health and social care providers, natural supports, and/or advocates to execute the individual’s Social Care Plan and ensure seamless service delivery.
• Assist individuals who are at the end of Enhanced HRSN service delivery to ensure service completion, identify persistent needs, and provide support in transitioning to additional supports (e.g., existing community programs), where relevant and desired.
• Maintain accurate and timely case notes and other relevant documentation in compliance with SCN requirements, Unite US expectations and best practices.
• Advocate on behalf of individuals to address barriers to accessing care and services.
• Attend and participate in regular team meetings, training, and development opportunities.
• Comply with all HCA policies and procedures, as well as applicable state and federal laws, rules and regulations related to the Social Care Network and the 1115 Waiver.
• This includes providing one-on-one support to individuals such as Accompanying them to appointments and assisting with completion/collection of applications or other documents.
• Collect and maintain all required statistical and other data and prepare reports within established timeframes.
• Attend all mandatory agency and departmental trainings, meetings, and advocacy groups.