Social Care Navigator I (Bilingual Spanish)

Essen Medical Associates•New York, NY

2d•$20 - $25•Hybrid

About The Position

Essen Health Care is seeking a Social Care Navigator I (SCN) to join NYREACH's Social Care Network. This role is crucial in connecting Medicaid members with essential social care services to improve their well-being. The SCN will conduct outreach, screen members for health-related social needs (HRSN) such as housing, food insecurity, transportation, and interpersonal safety, and assess their eligibility for enhanced HRSN services. A key aspect of this role is providing hands-on navigation and ensuring closed-loop referrals to community-based resources, following up to ensure needs are met. This specific SCN position will have a special focus on nutritional health, assisting members in accessing healthy food resources and nutrition-related services. The ideal candidate will possess strong communication and interpersonal skills, a passion for service, extensive knowledge of community resources, and experience in social services, community health, or care navigation.

Requirements

Bachelor’s degree in social work, human services, public health, community health, nutrition, or a related field.
Experience in social services, community health, care navigation, or a related field; familiarity with community resources and benefit programs.
Strong communication, interpersonal, and organizational skills; effective verbal and written communication is essential for interacting with members, providers, and other stakeholders.
Cultural sensitivity and the ability to adapt to different needs and work with a diverse population.
Comfort using technology platforms for screening, referrals, and documentation.
Bilingual Spanish required.

Nice To Haves

Background in nutrition, dietetics, or community nutrition.
Experience with HRSN screening, closed-loop referral platforms, or Medicaid populations.
Community Health Worker (CHW) training or lived experience in the communities served.

Responsibilities

Conduct proactive outreach to Medicaid members telephonically, in person, and in community settings to engage them in social care services.
Administer HRSN screenings to identify unmet social needs across domains including housing stability, food insecurity, transportation, and interpersonal safety.
Assess and document member eligibility for enhanced HRSN services in accordance with Social Care Network protocols.
Build rapport and trust with members, meeting them where they are and applying a person-centered, trauma-informed approach.
Connect members with appropriate community resources, including social service agencies, community-based organizations, healthcare providers, and government benefit programs.
Facilitate referrals to social care services, track each referral through to completion, and follow up with members and providers to confirm needs were addressed (closed-loop referral management).
Provide ongoing navigation support to members with complex or multiple needs, escalating and re-referring as circumstances change.
Collaborate with team members, partner-based navigators/CHWs, and community partners to coordinate care for members with complex needs and ensure seamless service delivery.
Use technology platforms to document member eligibility, outreach activities, case notes, referral outcomes, and other required data, adhering to established protocols and confidentiality standards.
Maintain accurate, timely records of all interactions, referrals, and outcomes.
Represent NYREACH at community events and cultivate working relationships with community organizations, partners, and healthcare facilities to strengthen the local resource network.
Perform other tasks assigned by the Senior Director of NYREACH.
Manage a caseload of assigned members with nutrition-related needs, connecting them to healthy food resources such as food pantries, benefits programs, medically tailored meals, and nutrition services.
Conduct workshops, seminars, one-on-one consultations, and presentations on healthy eating habits, disease prevention, and nutrition topics.
Provide personalized nutrition education to individuals and groups, focusing on healthy eating habits, meal planning, portion control, food preparation, and the impact of nutrition on overall health.