Social Care Navigator

Vanderheyden, Inc. • City of Troy, NY

7d • Hybrid

About The Position

The Social Care Navigator plays a crucial role in managing incoming referrals for enhanced HRSC services, ensuring timely and successful connections for community members. This position involves engaging Medicaid members through various channels (in-person, telephonic, virtual) to discuss referrals and address health-related social needs using a person-centered, culturally responsive, and trauma-informed approach. Key responsibilities include confirming service eligibility, coordinating referrals, providing longitudinal care management, conducting outreach, managing member consent, performing HRSN screenings and eligibility assessments, creating and overseeing social care plans, ensuring timely referral actions, documenting progress, monitoring eligibility changes, confirming service delivery, reporting on referral patterns, and participating in quality assurance activities. The role also requires maintaining confidentiality, complying with HIPAA and other regulations, attending required training, and performing other duties as assigned to support program objectives. A key performance indicator is meeting billable targets weekly, including a minimum of 5 screenings and assessments daily.

Requirements

• Minimum of associate’s degree in human services, public health, social work, or related field; bachelor's degree preferred.
• Experience in case coordination, care navigation, outreach, or direct service provision with Medicaid or underserved populations.
• Knowledge of SDOH/HRSN concepts and community-based service systems.
• Ability to follow standardized protocols for screening, assessing, referring, documentation, and follow-up.
• Demonstrated ability to maintain accurate, timely, and compliant records.
• Proficiency with electronic health records and/or DOH-aligned reporting systems.
• Strong organizational, communication, and interpersonal skills.
• Adherence to DOH guidance, Medicaid regulations, and 1115 Waiver service requirements is mandatory.
• All case coordination, screening, referral, and follow-up activities must be documented accurately to support reporting, utilization monitoring, and audit review.
• This job function involves potential access/interaction with protected health information. Position will be required to abide by company policies and procedures that support federal, state, and local HIPAA regulations. Any violations will be subject to company policy, which includes disciplinary actions up to and including separation of employment.
• Must have a valid NYS driver’s license with a clean MVR.

Nice To Haves

• Experience using translation services is preferred.
• Preferred experience in supporting individuals with disabilities.

Responsibilities

• Manage incoming referrals for enhanced HRSC services to ensure successful and timely connections are made for each community member.
• Engage Medicaid members in person, telephonically, or virtually to discuss referrals and work to assist in managing referrals to address health-related social needs using a person-centered, culturally responsive, and trauma-informed approach.
• Confirm eligibility for services, utilizing Epaces to ensure insurance is active and billable.
• Coordinate referrals with the individuals and document status of referrals to meet health-related social needs, including but not limited to housing instability, food insecurity, transportation barriers, utility needs, and interpersonal safety.
• Provide longitudinal care management for Members receiving one or more enhanced HRSN services.
• Conduct and document outreach to community members in alignment with required frequency, modality, and timeframe.
• Manage Member consent and attestation as required throughout the screening, assessment, and care management process.
• Conduct HRSN screening using the Accountable Health Communities (AHC) screening tool to assess member HRSNs.
• Conduct eligibility assessments to determine Member eligibility for enhanced HRSN services and refer Members to eligible programs and services, including enhanced HRSN services and/or existing federal, state, and local resources.
• Create and oversee social care plans that include a summary of Member needs, eligibility, and services to which they are referred.
• Ensure referrals are acted upon by HRSN service providers within required timeframes and redirect as necessary to support service connection. Document progress notes and action taken with each referral, as detailed in the Network Standards and Quality Program.
• Update the social care plan throughout service provision in collaboration with the Member and service provider to reflect strategies and interventions for meeting identified HRSNs.
• Monitor and manage eligibility status changes in collaboration with the Social Care Screener and Assistant Director of Care Management.
• Confirm service delivery completion and that Member needs have been addressed satisfactorily and support the transition to additional resources.
• Regularly use data and data tools to report referral patterns and trends to the management team.
• Share detailed feedback on the successes and challenges of the role with the Assistant Director of Care Management and continually look for opportunities to enhance and simplify the community member experience.
• Participate in quality assurance, data validation, and utilization monitoring activities related to 1115 Waiver reporting.
• Support internal reviews, corrective action plans, and external monitoring or audit requests assigned.
• Maintain confidentiality and comply with HIPAA, Medicaid, and DOH data privacy and security requirements.
• Attend required training related to DOH guidance, waiver updates, reporting requirements, and program compliance.
• Participate in supervision, team meetings, and case conferences as required.
• Perform other duties as assigned in support of DOH and 1115 Waiver program objectives.
• Meet billables weekly to ensure viability of program (minimum 5 screenings and assessments daily).

Benefits

• Vanderheyden is committed to the National Sanctuary Model - a blueprint for clinical and organizational change which, at its core, promotes safety and recovery from adversity through the active creation of a trauma-informed community. The Sanctuary Model's focus is not only on the people who seek services, but equally on the people and systems that provide those services.
• As an Equal Opportunity Employer, does not discriminate in its hiring or employment practices on the basis of gender, race or ethnicity, color, national origin, religion, age, disability, military or marital status, sexual orientation, gender identity or expression, domestic violence victim status, predisposing genetic characteristics or prior arrest or conviction record or any other category protected by applicable federal, state, or local laws

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree