Social Care Navigator

Mothers & Babies Perinatal Network•Village of Johnson City, NY

32d•Onsite

About The Position

The Social Care Navigator will operate within the framework of the Social Care Network, providing direct assistance to individuals to address Health-Related Social Needs (HRSN) and improve overall well-being. This role involves facilitating access to essential services such as housing, healthcare, nutrition, transportation, and other community resources. The Social Care Navigator collaborates closely with program members and relevant service providers to identify and address social determinants of health, and implements a comprehensive array of supports and services, improving health outcomes and quality of life.

Requirements

Strong commitment to the independent living philosophy, Person Centered Planning, consumer choice and integration of people with disabilities into all aspects of community life.
Knowledge of available community and clinical services in the SCNY region.
Proficient in use of all Microsoft Office applications (Excel, Word, Power Point).
Strong customer service skills – friendly, compassionate, engaging, yet professional; ability to effectively interact and work with individuals from diverse cultures and backgrounds.
Strong oral and written communication skills.
Demonstrated professional work habits including dependability, time management, independence, and responsibility.
Knowledge of ethical and professional responsibilities and boundaries.
Excellent attention to detail and organizational skills.
Ability to multi-task and work effectively in both a team and individual setting.
Valid driver’s license and reliable vehicle.
Travel as needed for the job through a six-county service area.
Education: Associate Degree in Social Work, Human Services or a related field and:
2 years’ experience in care management, social service needs.
An equivalent combination of education and experience.

Responsibilities

Complete Orientation & Training provided by M&BPN.
Documentation & Reporting: To accurately obtain and record and enter data into MPBN Client database. Maintain accurate case notes and other relevant documentation in compliance with SCN requirements and State & Federal guidelines. Collect and maintain all required records, reports and require statistical or other data.
Assess a client’s initial eligibility for Enhanced HRSN services following the SCN Screening that confirmed unmet Social Needs.
Conduct interim eligibility assessments to determine if a client has experienced a status change that results in change of eligibility for Enhanced HRSN or other services and inform the SCN Lead Entity and HRSN Service Providers of any needed changes to the client’s service eligibility. (Ex, the needs to end services or change end of service delivery dates when a client’s Medicaid enrollment status changes.)
Refer eligible clients to appropriate Enhanced HRSN to meet their needs.
Collaborate with clients eligible for Enhanced HRSN to establish goals and develop and implement an individualized Social Care Plan. Utilize closed loop referral system to receive, track, and manage referrals to community services and document client engagement and outcomes.
Track client’s progress in achieving the goals and desired outcomes outline in the Social Care Plan.
Serve as the single point of contact for the client and work with other related health and social care providers and support and advocate ensuring the client’s Social Care Plan is a seamless service delivery.
Assist Client who are at the end of their services delivery to ensure their need Enhanced HRSN services are completed, identify persistent needs, and provide support into transitioning services and support. This will also include helping and or advocating for the client to navigate barriers.
Ability to enter data, notes and other documentation into computer and multiple databases.
Complete client follow-up/progress notes on each encounter and ensure client records are up to date.
Attend all mandatory agency and department training courses, meetings and other groups as needed.
Comply with all MBPN policies and procedures, as well as applicable state, and federal laws, rules and regulations related to the Social Care Network and the 1115 Waiver.