Care Navigator (Community-Based & Field Navigation) - New York na Mom's Meals

Responsibilities include, but are not limited to

• Conduct standardized health-related social needs screenings in accordance with state and program requirements in community, partner organization, virtual, and telephonic settings
• Complete eligibility assessments and supporting documentation for social care services and enhanced navigation programs
• Provide in-person screening and navigation support at community events, health fairs, enrollment events, and outreach activities
• Build and maintain relationships with community-based organizations, healthcare providers, and local partners to increase awareness of available social care services
• Serve as an embedded Care Navigator within designated partner organizations, as assigned, providing on-site screening, referral coordination, and navigation services
• Initiate, monitor, and close referrals within designated referral management platforms
• Accurately document service activities, encounters, outcomes, and time spent in accordance with program billing and reporting requirement
• Perform closed-loop referral follow-up activities to confirm successful service connections and identify unresolved barriers
• Conduct outreach attempts and engagement activities in accordance with program timelines and documentation standards
• Educate individuals, caregivers, and community stakeholders regarding available benefits, community resources, and social care services
• Coordinate with healthcare providers, managed care organizations, community-based organizations, and other stakeholders to support continuity of care
• Represent the organization professionally in community settings and act as an ambassador for care navigation programs and services
• Escalate complex cases, urgent social needs, safety concerns, or barriers to supervisory or clinical staff as appropriate
• Maintain compliance with HIPAA, confidentiality requirements, and all applicable federal, state, and program regulations
• Meet productivity, quality, timeliness, documentation, and engagement standards established by the organization and program requirements
• Participate in ongoing training, workflow development, community engagement initiatives, and quality improvement activities
• Support reassessment, renewal, and recertification activities as required by program guidelines

Required Skills and Experience

• Minimum of 2 years’ experience in healthcare, social services, behavioral health, community outreach, case management, care coordination, human services, or a related field
• Experience engaging individuals from diverse communities and backgrounds with empathy, professionalism, and cultural humility
• Ability to build rapport quickly in both community-based and telephonic settings
• Experience conducting direct client interactions in-person, telephonically, or through community outreach activities
• Strong verbal, written, and interpersonal communication skills
• Ability to present information effectively to individuals, families, community partners, and stakeholders
• Strong organizational skills with the ability to manage multiple priorities, locations, and deadlines simultaneously
• Ability to maintain accurate and detailed documentation in compliance with regulatory and organizational requirements
• Proficiency with Microsoft Office applications and technology platforms used for documentation and referral management 
• Ability to work independently, exercise sound judgment, and adapt to changing community and program needs
• Valid driver's license, reliable transportation, and ability to travel regularly throughout assigned service areas
• Ability to routinely use laptops, smartphones, and other mobile technology while working remotely and in the field

Preferred Skills and Experience

• Training or certification in Trauma-Informed Care, Motivational Interviewing, Crisis Intervention, and/or De-escalation Techniques
• Experience working within New York Medicaid, Social Care Network (SCN), Managed Care, 1115 Waiver, or Health Equity initiatives
• Experience providing care navigation, care management, community health worker services, outreach, health coaching, benefits navigation, or case management
• Experience conducting community outreach, tabling events, health fairs, enrollment events, or grassroots engagement activities
• Experience working with individuals experiencing food insecurity, housing instability, behavioral health conditions, substance use disorders, transportation barriers, justice involvement, or other social determinants of health
• Bilingual proficiency preferred, particularly Spanish, Mandarin, Cantonese, Russian, Bengali, Haitian Creole, Arabic, or other languages commonly spoken in New York communities
• Established knowledge of community resources and service networks within New York State

Physical Requirements

• Repetitive motions that include the wrists, hands and/or fingers
• Sedentary work that primarily involves sitting, remaining in a stationary position for prolonged periods
• Visual perception to perform job including peripheral vision, depth perception, and the ability to adjust focus