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

Essen Medical Associates•Forest Hills, NY

2d•Onsite

About The Position

NYREACH is an independent 501(c)(3) nonprofit serving Bronx County through health-equity initiatives, community-based programs, and direct services. The Social Care Navigator I is the front line of NYREACH’s Social Care Network, connecting Medicaid members with social care services. The role conducts outreach and health-related social needs (HRSN) screenings, assesses eligibility for enhanced HRSN services, and provides hands-on navigation and closed-loop referrals to community resources. The Navigator builds trusted relationships with members and follows referrals through to completion. The position has a special focus on nutritional health, helping members access healthy food and nutrition-related services and providing nutrition education. This is a full-time, field-based role involving regular local travel throughout the service area; remote or fully in-office arrangements are not available.

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 for needs including housing stability, food insecurity, transportation, and interpersonal safety.
Assess and document 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; escalate and re-refer as circumstances change.
Coordinate with team members, partner-based navigators and community health workers, and community partners to support seamless care.
Use technology platforms to document eligibility, outreach, case notes, referral outcomes, and other required data in accordance with protocols and confidentiality standards.
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 topics.
Provide nutrition education on healthy eating, meal planning, portion control, food preparation, and nutrition’s impact on health.
Meet or exceed monthly screening and outreach targets and maintain closed-loop referral completion in line with program benchmarks.
Complete required documentation within established timeframes; same-day entry is required for screenings and referrals.
Maintain an active nutrition-related caseload and deliver nutrition education consistently.
Perform other tasks assigned by the Senior Director of NYREACH.