Social Care Network Navigator & Diversion Specialist

Independent Living Inc•City of Middletown, NY

10d•Hybrid

About The Position

The Social Care Network Navigator & Diversion Specialist plays a vital role in improving health outcomes by connecting individuals with health-related social needs, behavioral health concerns, housing instability, substance use challenges, and other barriers to community living with appropriate supports and services. Working in both hospital and community settings, this position conducts screenings, determines eligibility for services, provides recovery-oriented peer support, and coordinates referrals through the Social Care Network (SCN) and other community-based resources. The Social Care Network Navigator & Diversion Specialist serves as a compassionate advocate, helping individuals navigate complex systems of care while promoting self-determination, reducing unnecessary hospitalizations, and strengthening connections to community supports.

Requirements

High School Diploma or GED.
Must complete all required Hudson Valley Care Coalition (HVCC) Social Care Network screening and navigation training during the first week of employment.
Must successfully complete all required hospital and other partnership onboarding requirements, including medical clearances, trainings, and compliance requirements necessary to provide services in those settings.
Demonstrated ability to assess individual needs and connect participants with appropriate community resources and disability-related services.
Lived experience with mental health recovery, substance use recovery, homelessness, disability, or other life challenges and a desire to use those experiences to support others is strongly encouraged.
Strong understanding of person-centered, trauma-informed, and recovery-oriented service delivery.
Excellent communication, interpersonal, and advocacy skills with the ability to build trust across diverse populations.
Knowledge of community resources, disability services, behavioral health systems, housing supports, and social service programs.
Strong organizational, documentation, time management, and problem-solving skills with the ability to work independently.
Basic computer proficiency and the ability to navigate electronic referral systems, databases, and case management software.
Must possess a valid, unrestricted driver's license and reliable transportation.

Nice To Haves

Experience working within social services, healthcare navigation, behavioral health, care coordination, peer support, or community outreach programs.
Certified Recovery Peer Advocate (CRPA) credential.
NYCPS (New York Certified Peer Specialist) certification.
Familiarity with UniteUs, Foothold, or similar case management and referral platforms.
Knowledge of Medicaid populations, Health-Related Social Needs (HRSN), and Social Care Network initiatives.
Bachelor’s degree in human services, Social Work, Psychology, Public Health, or a related field.
Bilingual English/Spanish skills or proficiency in American Sign Language (ASL).
Established knowledge of local behavioral health, housing, disability, and community support resources.

Responsibilities

Conduct comprehensive health-related social needs screenings, benefits eligibility assessments, and contracted service assessments using approved SCN screening tools.
Accept and manage referrals through UniteUs and other referral platforms, ensuring timely outreach, engagement, and follow-up.
Provide outreach and navigation services to Medicaid populations in hospitals, emergency departments, and community settings.
Conduct Screenings, Navigation and Contracted Services from the Emergency Department at St. Lukes Montefiore in Newburgh on a rotating basis 2-3 days a week and in other community settings as needed.
Assess participant eligibility for available services and coordinate referrals to appropriate community-based organizations and supports.
Provide peer-based support, encouragement, advocacy, and recovery-oriented coaching to individuals experiencing mental health challenges, substance use concerns, housing instability, social isolation, or other life challenges.
Support individuals in developing recovery plans, wellness strategies, psychiatric advance directives, and other person-centered goals that promote independence and self-determination.
Collaborate with hospitals, mobile crisis teams, behavioral health providers, law enforcement agencies, care managers, and community organizations to coordinate services and improve continuity of care.
Follow up with participants to ensure referrals have been successfully completed, and health-related social needs have been addressed.
Maintain current knowledge of SCN services, community resources, Medicaid programs, behavioral health services, housing supports, and disability-related resources.
Advocate for participants by helping them overcome barriers, access services, strengthen self-advocacy skills, and navigate complex service systems.
Document all outreach activities, screenings, referrals, follow-up services, and participant interactions accurately in UniteUs, Foothold, and other required databases.
Work collaboratively with program leadership to improve workflows, identify service gaps, and implement quality improvement initiatives.
Prepare participant success stories and outcome summaries that demonstrate program impact.
Complete all required reports, maintain accurate records, and participate in required meetings, supervision, trainings, and hospital onboarding activities.
Perform other duties as assigned to support program operations.