Care Navigator (Community-Based & Field Navigation) - New York

Moms Meals, Ltd; New York (NY); Remote; USD 34,000 - 36,000; Full time

Job summary

Mom’s Meals is seeking a Care Navigator to support Medicaid members and other eligible populations across New York in a hybrid role with local travel. Responsibilities include screenings, eligibility assessments, on-site navigation at events, and referral management to connect clients with social care services.

The role emphasizes trauma-informed, culturally responsive care, collaboration with partner organizations, and accurate documentation while traveling across New York State.

Qualifications

• Minimum of 2 years’ experience in healthcare, social services, behavioral health, community outreach, case management, care coordination, human services, or a related field.
• Experience engaging individuals from diverse communities and backgrounds with empathy, professionalism, and cultural humility.
• Ability to build rapport quickly in both community-based and telephonic settings.
• Experience conducting direct client interactions in-person, telephonically, or through community outreach activities.
• Strong verbal, written, and interpersonal communication skills.

Responsibilities

• Conduct standardized health-related social needs screenings in accordance with state and program requirements in community, partner organization, virtual, and telephonic settings
• Complete eligibility assessments and supporting documentation for social care services and enhanced navigation programs
• Provide in-person screening and navigation support at community events, health fairs, enrollment events, and outreach activities
• Build and maintain relationships with community-based organizations, healthcare providers, and local partners to increase awareness of available social care services
• Serve as an embedded Care Navigator within designated partner organizations, as assigned, providing on-site screening, referral coordination, and navigation services
• Initiate, monitor, and close referrals within designated referral management platforms
• Accurately document service activities, encounters, outcomes, and time spent in accordance with program billing and reporting requirement
• Perform closed-loop referral follow-up activities to confirm successful service connections and identify unresolved barriers
• Conduct outreach attempts and engagement activities in accordance with program timelines and documentation standards
• Educate individuals, caregivers, and community stakeholders regarding available benefits, community resources, and social care services
• Coordinate with healthcare providers, managed care organizations, community-based organizations, and other stakeholders to support continuity of care
• Represent the organization professionally in community settings and act as an ambassador for care navigation programs and services
• Escalate complex cases, urgent social needs, safety concerns, or barriers to supervisory or clinical staff as appropriate
• Maintain compliance with HIPAA, confidentiality requirements, and all applicable federal, state, and program regulations
• Meet productivity, quality, timeliness, documentation, and engagement standards established by the organization and program requirements
• Participate in ongoing training, workflow development, community engagement initiatives, and quality improvement activities
• Support reassessment, renewal, and recertification activities as required by program guidelines

Skills

Healthcare experience

Care coordination

Cultural humility

Community outreach

Empathy

Communication skills

Documentation

Microsoft Office

Travel willingness

Driver's license

Job description

The Care Navigator supports Medicaid members and other eligible populations participating in New York Social Care Network (SCN), 1115 Waiver, In Lieu of Services (ILOS), Value-Added Benefit (VAB), and related programs. The role helps individuals identify and address health-related social needs by connecting them with appropriate services and resources.

This position delivers person-centered, culturally responsive, and trauma-informed navigation through community-based, field, telephonic, and technology-enabled settings. The Care Navigator reports to the Care Navigation Program Manager and works in a New York-based hybrid role requiring regular local travel, with occasional travel within New York State.

The ideal candidate is equally comfortable engaging individuals at a busy community event, building relationships with partner organizations, and providing ongoing navigation support by phone. They are passionate about improving health equity, connecting people to critical services, and serving as a visible, trusted presence within the communities they support.

Hourly Range: $25-26/hour

NOTE: This is two openings for any posted location in New York. Please only apply for ONE position.

Responsibilities include, but are not limited to

• Conduct standardized health-related social needs screenings in accordance with state and program requirements in community, partner organization, virtual, and telephonic settings

• Complete eligibility assessments and supporting documentation for social care services and enhanced navigation programs

• Provide in-person screening and navigation support at community events, health fairs, enrollment events, and outreach activities

• Build and maintain relationships with community-based organizations, healthcare providers, and local partners to increase awareness of available social care services

• Serve as an embedded Care Navigator within designated partner organizations, as assigned, providing on-site screening, referral coordination, and navigation services

• Initiate, monitor, and close referrals within designated referral management platforms

• Accurately document service activities, encounters, outcomes, and time spent in accordance with program billing and reporting requirement

• Perform closed-loop referral follow-up activities to confirm successful service connections and identify unresolved barriers

• Conduct outreach attempts and engagement activities in accordance with program timelines and documentation standards

• Educate individuals, caregivers, and community stakeholders regarding available benefits, community resources, and social care services

• Coordinate with healthcare providers, managed care organizations, community-based organizations, and other stakeholders to support continuity of care

• Represent the organization professionally in community settings and act as an ambassador for care navigation programs and services

• Escalate complex cases, urgent social needs, safety concerns, or barriers to supervisory or clinical staff as appropriate

• Maintain compliance with HIPAA, confidentiality requirements, and all applicable federal, state, and program regulations

• Meet productivity, quality, timeliness, documentation, and engagement standards established by the organization and program requirements

• Participate in ongoing training, workflow development, community engagement initiatives, and quality improvement activities

• Support reassessment, renewal, and recertification activities as required by program guidelines

Required Skills and Experience

• Minimum of 2 years’ experience in healthcare, social services, behavioral health, community outreach, case management, care coordination, human services, or a related field

• Experience engaging individuals from diverse communities and backgrounds with empathy, professionalism, and cultural humility

• Ability to build rapport quickly in both community-based and telephonic settings

• Experience conducting direct client interactions in-person, telephonically, or through community outreach activities

• Strong verbal, written, and interpersonal communication skills

• Ability to present information effectively to individuals, families, community partners, and stakeholders

• Strong organizational skills with the ability to manage multiple priorities, locations, and deadlines simultaneously

• Ability to maintain accurate and detailed documentation in compliance with regulatory and organizational requirements

• Proficiency with Microsoft Office applications and technology platforms used for documentation and referral management

• Ability to work independently, exercise sound judgment, and adapt to changing community and program needs

• Valid driver's license, reliable transportation, and ability to travel regularly throughout assigned service areas

• Ability to routinely use laptops, smartphones, and other mobile technology while working remotely and in the field

Preferred Skills and Experience

• Training or certification in Trauma-Informed Care, Motivational Interviewing, Crisis Intervention, and/or De-escalation Techniques

• Experience working within New York Medicaid, Social Care Network (SCN), Managed Care, 1115 Waiver, or Health Equity initiatives

• Experience providing care navigation, care management, community health worker services, outreach, health coaching, benefits navigation, or case management

• Experience conducting community outreach, tabling events, health fairs, enrollment events, or grassroots engagement activities

• Experience working with individuals experiencing food insecurity, housing instability, behavioral health conditions, substance use disorders, transportation barriers, justice involvement, or other social determinants of health

• Bilingual proficiency preferred, particularly Spanish, Mandarin, Cantonese, Russian, Bengali, Haitian Creole, Arabic, or other languages commonly spoken in New York communities

• Established knowledge of community resources and service networks within New York State

Physical Requirements

• Repetitive motions that include the wrists, hands and/or fingers

• Sedentary work that primarily involves sitting, remaining in a stationary position for prolonged periods

• Visual perception to perform job including peripheral vision, depth perception, and the ability to adjust focus

Company Overview

Mom’s Meals is a home-delivered meal service providing fully prepared, refrigerated meal solutions direct to homes nationwide since 1999. We provide seniors, patients recovering post-discharge and those managing a chronic condition with tailored nutrition solutions to manage their specific needs. If you are passionate about the well-being of others and have a strong sense of community, Mom’s Meals could be the place for you! We are a family operated business looking for fun, compassionate, and friendly people who want to make a difference in the lives of others.

EEO

Mom’s Meals complies with all applicable federal and state non-discrimination laws. All qualified applicants shall receive consideration for employment without regards to race, religion, national origin, ancestry, color, gender, age, disability, sexual orientation or military status.

Job Category: Corporate – Sales & Marketing

Job Type: Full-Time, Remote

Location Type: Remote