The Community Health Worker (CHW) – Social Care Network Specialist plays a key role in advancing the New York State 1115 Medicaid waiver’s focus on addressing health-related social needs (HRSN). This role emphasizes conducting comprehensive HRSN assessments, connecting individuals and families to community resources, and coordinating services through Social Care Networks (SCNs). The CHW acts as a trusted bridge between healthcare systems, social care providers, and the communities served.
PRIMARY FUNCTIONS:
Health-Related Social Needs (HRSN) Assessments:
- Conduct thorough HRSN assessments to identify barriers to health such as housing instability, food insecurity, transportation challenges, and lack of access to social services.
- Use standardized tools and evidence-based practices to evaluate client needs and strengths.
- Prioritize outreach to Medicaid members with complex needs or at high risk for poor health outcomes.
Client Support and Navigation:
- Develop personalized action plans based on HRSN assessment findings.
- Provide direct support to clients in accessing community resources and overcoming systemic barriers.
- Offer culturally competent education on available services and empower clients to advocate for their needs.
Referral Coordination within Social Care Networks (SCNs):
- Leverage SCN platforms (Unite Us) to initiate and track referrals.
- Work closely with SCN partners to ensure timely and effective service delivery.
- Monitor and document referral outcomes, ensuring clients' needs are adequately addressed.
Collaboration with Healthcare Providers and Community Stakeholders:
- Partner with managed care organizations (MCOs), healthcare providers, and community-based organizations (CBOs) to integrate social and healthcare services.
- Facilitate communication between clients and medical providers, ensuring HRSN are addressed alongside clinical care.
- Participate in care team meetings to share assessment findings and collaborate on care coordination.
- Field-based role involving home visits, community outreach, and coordination with local agencies.
Data Collection and Reporting:
- Maintain accurate and detailed records of HRSN assessments, client interactions, and outcomes.
- Analyze data to identify trends, service gaps, and areas for improvement in addressing HRSN.
- Contribute to the evaluation of the SCN’s impact on health outcomes and the 1115 waiver goals.
Community Engagement and Capacity Building:
- Build partnerships with community leaders and organizations to expand access to resources.
- Educate stakeholders about the importance of HRSN and the integration of social and healthcare services.
- Assist in the development of educational materials to support client understanding of available services.
ADDITIONAL FUNCTIONAL / ORGANIZATIONAL SUPPORT:
N/A
QUALIFICATIONS AND ATTRIBUTES:
Strong organization skills with accurate attention to detail
Excellent communication skills and the ability to multi- task
Knowledgeable and skilled in understanding and educating others on healthcare, healthcare systems, healthcare reform, pathways to care, and communication with community providers.
Experience conducting assessments, especially related to HRSN, in healthcare or social service settings.
Familiarity with Medicaid programs, 1115 waiver initiatives, and SDOH frameworks.
Excellent interpersonal, communication, and problem-solving skills.
Proficiency with electronic data systems and referral platforms.
Excellent verbal, written and presentation skills.
Bilingual or multilingual abilities preferred.
EDUCATION AND EXPERIENCE:
High school diploma or equivalent required; associate or bachelor’s degree in social work, public health, or a related field preferred.
Completion of a recognized Community Health Worker training program preferred.
PHYSICAL CHARACTERISTICS:
Must be capable to sit or stand in front of a computer for long-periods of time
Able to work in open space floor plan
Must be capable to move throughout work day and work with people in the community (people we serve and providers)
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