Hybrid Social Care Navigator en Access-Supports for Living
Access-Supports for Living · Mt. Vernon, Estados Unidos De América · Hybrid
- Junior
- Oficina en Mt. Vernon
Location: Mt. Vernon, NY
Hours: M-F
Rate of Pay: $21.63
OVERVIEW OF PRIMARY RESPONSIBILITES:
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)
- Work alongside co-workers within 3 feet
- Occasional lifting of > _25+ pounds
EEO
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