SCN Enhanced Care Manager

Forward Leading IPA•Rochester, NY

12d•Hybrid

About The Position

The Enhanced Care Manager serves as a dedicated care management resource supporting high risk/specialty population members who are eligible to receive enhanced services across the Social Care Network (SCN), including maternal-child health (MCH), postpartum individuals, children and youth, members requiring asthma remediation services, and sensitive conditions population including SUD, SMI, and IDD. This position operates within SCN's Internal Hub using a hybrid embedded model that combines direct community-based engagement with centralized care coordination activities. The Enhanced Care Manager is responsible for completing Health Related Social Needs (HRSN) screening and Eligibility Assessment, care planning, referral management, cross-sector collaboration, member engagement, service coordination, and outcome tracking. This role helps SCN fulfill its commitment to improving health outcomes and reducing barriers for vulnerable populations.

Requirements

Bachelor’s degree in social work, Human Services, Public Health, Nursing, Psychology, or a related field.
Minimum of two years of experience in care management, case management, care coordination, community health, social services, or a related area.
Experience working with vulnerable, high-need, or underserved populations.
Knowledge of community resources, healthcare systems, social service systems, and referral processes.
Strong communication, organization, documentation, and relationship-building skills.
Ability to work independently, manage multiple priorities, and collaborate effectively with internal and external partners.

Nice To Haves

Experience in maternal and child health, behavioral health, substance use services, developmental disability services, or other specialty population programs.
Knowledge of New York State Medicaid, managed care, Social Care Networks, or health-related social needs programming.
Care management certification, community health worker certification, or equivalent professional credential.
Bilingual or multilingual abilities.
Care coordination and care management
Trauma-informed and person-centered engagement
Community partnership development
Member advocacy and resource navigation
Documentation, compliance, and confidentiality
Communication, organization, and time management
Problem-solving, critical thinking, and sound judgment
Collaboration across healthcare, social service, and community-based partners

Responsibilities

Manage a dedicated caseload of members within identified high-risk and specialty populations.
Complete screenings and assessments to identify members’ health-related social needs, eligibility, and service needs.
Develop, implement, and update individualized care plans based on each member’s needs, goals, and available resources.
Connect members to appropriate providers, programs, community resources, and social care services.
Monitor member progress, referral outcomes, and service engagement throughout the care management process.
Provide ongoing support, education, and follow-up to help members navigate services and reduce barriers to care.
Facilitate warm handoffs to appropriate services and community-based supports.
Build and maintain trusted relationships with members, families, healthcare providers, and community partners.
Participate in multidisciplinary case reviews, care conferences, and collaborative planning meetings as needed.
Work onsite or in coordination with partner organizations, including OB/GYN practices, WIC offices, Federally Qualified Health Centers, schools, home visiting programs, and community-based organizations.
Coordinate referrals, service follow-up, and communication across internal and external partners.
Conduct care plan reviews and support ongoing care management activities through SCN-approved processes.
Maintain regular communication and collaboration with healthcare providers, community organizations, and internal team members.
Use multiple systems, workflows, and documentation processes to support timely and accurate care coordination.
Document all member interactions, referrals, care management activities, and follow-up actions in SCN-approved systems.
Maintain accurate, timely, and complete documentation in accordance with SCN, organizational, and regulatory requirements.
Ensure care management activities are completed in alignment with applicable program standards and compliance expectations.
Track referral outcomes, service completion, member engagement, and barriers to care.
Support reporting, performance monitoring, and quality improvement initiatives related to care management services.
Protect member confidentiality and handle sensitive information in accordance with applicable privacy requirements.