Social Care Navigator I — Field-Based (Bilingual Spanish)

Essen Medical Associates•Town of Perinton, NY

3d•$23 - $25•Onsite

About The Position

The Social Care Navigator I (SCN) is the front line of NYREACH’s Social Care Network, connecting Medicaid members to social care services. The role conducts outreach, screens members for health-related social needs (HRSN), assesses eligibility for enhanced HRSN services, and provides hands-on navigation and closed-loop referrals to community-based resources. The SCN builds trusted relationships with members and follows referrals through to completion so members remain connected between screening and service delivery. The position has a special focus on nutritional health, helping members access healthy food resources and nutrition-related services. The SCN manages an assigned caseload of members with nutrition-related needs and provides nutrition education through workshops, seminars, presentations, and one-on-one consultations. This is a full-time, field-based position serving the Bronx; remote or fully in-office arrangements are not available. Regular local travel between community events, partner organizations, healthcare facilities, and other assigned locations is required. The schedule is Monday through Friday, 9:00 AM to 5:00 PM, with one weekend day per month potentially required.

Requirements

High school diploma or GED.
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, including effective verbal and written communication.
Cultural sensitivity and 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

Associate’s or bachelor’s degree in social work, human services, public health, community health, nutrition, or a related field.
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 by phone, in person, and in community settings.
Administer HRSN screenings covering needs such as housing stability, food insecurity, transportation, and interpersonal safety.
Assess and document member eligibility for enhanced HRSN services according to Social Care Network protocols.
Build rapport with members using a person-centered, trauma-informed approach.
Connect members with social service agencies, community-based organizations, healthcare providers, and government benefit programs.
Facilitate referrals, track them through completion, and follow up with members and providers to confirm services were received.
Provide ongoing navigation for members with complex or multiple needs, escalating and re-referring as circumstances change.
Coordinate care with team members, partner-based navigators and community health workers, and community partners.
Document eligibility, outreach, case notes, referral outcomes, and other required data using technology platforms and established confidentiality protocols.
Maintain accurate and timely records of interactions, referrals, and outcomes.
Represent NYREACH at community events and develop working relationships with community organizations, partners, and healthcare facilities.
Manage a caseload of members with nutrition-related needs and connect them to food pantries, benefits programs, medically tailored meals, and nutrition services.
Conduct workshops, seminars, consultations, and presentations on healthy eating, disease prevention, and nutrition.
Provide individualized and group nutrition education on healthy eating, meal planning, portion control, food preparation, and nutrition’s impact on health.
Meet or exceed monthly HRSN screening and outreach targets and program benchmarks for closed-loop referral completion.
Complete required documentation within established timeframes, including same-day entry for screenings and referrals.
Maintain an active nutrition-related caseload and deliver nutrition education sessions consistently.
Maintain productive relationships with partner organizations and healthcare facilities and uphold professional, accurate, member-centered communication.
Perform other tasks assigned by the Senior Director of NYREACH.