Social Care Navigator

Southern Tier Independence Center
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Position Title Social Care Navigator
HR USE ONLY

Date Issued 12/2024 Hour Per Week/ Status
40 hours/FT

Date Revised 12/2024 Hourly Rate $20.00/hour

Reports to
Transition Director

FSLA Status
Non-Exempt

Department
Social Care Network
Location

Broome

Summary
The Social Care Navigator will operate 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.

Education and Experience
1. Associate’s degree in Social Work, Human Services, or a related field; and
2. Two years’ experience in care management, social services; or
3. An equivalent combination of education and experience.

Knowledge, Skills, and Abilities
1. Strong commitment to the independent living philosophy, Person Centered Planning, consumer choice and

integration of people with disabilities into all aspects of community life.
2. Ability to effectively interact and work with individuals from diverse cultures and backgrounds.
3. Proficient in the use of all Microsoft Office applications (Excel, Word, Power Point).
4. Ability to communicate effectively, both verbally and in writing.
5. Demonstrate professional work habits including dependability, time management, independence and

responsibility.
6. Knowledge of ethical and professional responsibilities and boundaries.
7. Excellent attention to detail and organizational skills.
8. Ability to multi-task and work effectively in both a team and individual setting.
9. Capacity to work in various settings, including home visits and community-based locations.
10. Valid Driver’s License and reliable vehicle.

Essential Job Functions
1. Assess a member's initial eligibility for Enhanced HRSN services following an SCN Screening that

confirmed unmet Health Related Social Needs.
2. Conduct interim eligibility assessments to determine if a member has experienced a status change

that results in eligibility changes for Enhanced HRSN or other services and inform the SCN Lead
Entity and HRSN Service Providers of any needed changes to service delivery (e.g., the need to end
services or change end of service delivery dates when a Member’s Medicaid enrollment status
changes).

3. Refer eligible members to appropriate Enhanced HRSN to meet their needs.
4. Collaborate with members eligible for Enhanced HRSN to establish goals and develop and implement an

individualized Social Care Plan. Track members’ progress in achieving the goals and desired outcomes

outlined in their Social Care Plan.
5. Serve as a single point of contact for the Member and work with related health and social care providers,

natural supports, and/or advocates to execute the member’s Social Care Plan and ensure seamless
service delivery.

6. Update the Social Care Plan throughout services as needed and with notes helpful to support service
coordination by health and social care professionals.

7. Assist members 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.

8. Assist members who are not eligible for/opt out of Enhanced HRSN services or need additional
support beyond Enhanced HRSN services to access relevant existing community and health care
supports and services. This includes providing one-on-one support to members such as
Accompanying them to appointments and assisting with completion/collection of applications or other
documents.

9. Utilize a closed-loop referral system to receive, track and manage referrals to community services, and
document member engagements and outcomes.

10. Maintain accurate case notes and other relevant documentation in compliance with SCN
requirements and state and federal guidelines.

11. Advocate on behalf of members to address barriers to accessing care and services.
12. Attend and participate in regular team meetings, training, and development opportunities.
13. Comply with all STIC policies and procedures, as well as applicable state and federal laws, rules and

regulations related to the Social Care Network and the 1115 Waiver.
14. Collect and maintain all required statistical and other data and prepare reports within established

timeframes.
15. Attend all mandatory agency and departmental trainings, meetings, and sign language class and

advocacy groups.
16. Regularly travel throughout a six county service area.

Physical Requirements/Working Conditions
1. Work is typically performed indoors and requires minimal lifting of up to 10 pounds.
2. Position requires member home visits.
3. Ability to sit/stand throughout day to accomplish job.
4. Ability to enter data, notes, and other documentation into a computer.
5. Must be able to travel throughout covered counties in and around the Southern Tier as needed. This may

also include travel to regional- or state-level meetings or functions within NYS on occasion.

Reasonable accommodations may be made to the extent required under applicable law to enable
individuals with disabilities to perform the essential functions of this position.

The statements herein are intended to describe the general nature and level of work being performed, but are
not to be seen as a complete list of responsibilities, duties, skills, required of personnel so classified. Also, they
do not establish a contract for employment and are subject to change at the direction of the employer.

I have read and understand the responsibilities outlined in this job description.

Southern Tier Independence Center, Inc. is an equal opportunity employer. It is our policy to hire the best
qualified applicant for the position, without regard to: gender; gender identity/expression; sexual orientation;
disability; age; race; color; creed; national origin; pre-disposing genetic characteristics; military, familial, marital
or domestic violence survivor status; pregnancy or pregnancy-related conditions; criminal history; or any other
protected class included in applicable local, state or federal laws.