Social Care Navigator

Vanderheyden Hall Inc.; New York (NY); Hybrid; USD 52,000 - 76,000; Full time

Job summary

Vanderheyden Hall Inc. seeks a qualified professional to manage referrals for enhanced HRSN services, engage Medicaid members, and coordinate care plans addressing housing instability, food insecurity, transportation, and safety.

The role emphasizes trauma-informed, person-centered care and HIPAA compliance within a hybrid work model. Responsibilities include conducting HRSN screenings, determining eligibility for services, documenting progress, updating social care plans, and reporting trends

Qualifications

• Minimum associate’s degree in human services, public health, social work, or a 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.

Responsibilities

• Manage incoming referrals for enhanced HRSC services to ensure timely connections.
• Engage Medicaid members in person, telephonically, or virtually to discuss referrals and assist in managing referrals.
• Confirm eligibility for services and ensure insurance is active and billable.
• Coordinate referrals with individuals and document status to address health-related social needs.
• Provide longitudinal care management for members receiving enhanced HRSN services.
• Adhere to required frequency, modality, and timeframe for outreach to community members.
• Manage member consent and attestation throughout screening and care management.
• Conduct HRSN screening using the AHC tool and assess member eligibility for enhanced services.
• Refer members to eligible programs and/or federal, state, and local resources.
• Create and oversee social care plans detailing needs, eligibility, and services.
• Ensure referrals are acted upon within required timeframes and document progress.
• Update social care plans during service provision with members and providers.
• Monitor eligibility status changes with the Social Care Screener and Assistant Director of Care Management.
• Confirm service delivery completion and support transitions to additional resources.
• Use data tools to report referral patterns and trends to management.
• Provide feedback on successes and challenges to improve member experience.
• Participate in QA, data validation, and utilization monitoring for 1115 Waiver reporting.
• Support internal reviews, corrective action plans, and audit requests.
• Maintain HIPAA and data privacy compliance.
• Attend required training on DOH guidance and waiver updates.
• Participate in supervision, team meetings, and case conferences.
• Perform other duties to support DOH and 1115 objectives.
• Meet billables weekly (minimum 5 screenings and assessments daily).

Skills

Case coordination

Care navigation

Outreach

Medicaid experience

SDOH/HRSN concepts

EHR systems

Communication skills

Organizational skills

Education

Associate’s degree in human services, public health, social work, or related field

Bachelor’s degree preferred

Job description

This is a grant-funded position with a projected end date in March 2027.

Primary Duties & Essential Functions:

• 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).

Required Education, Knowledge, and Skills:

• 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.

Abilities and Working Conditions:

• Knowledge and understanding of health equity, social drivers of health, and social care data.
• Excellent communication and presentation skills.
• Experience using translation services is preferred.
• Ability to build collaborative working relationships with others inside and outside the organization through cooperation, mutual respect, and capacity to inspire and motivate others.
• Thrive working with multiple systems and processes.
• Demonstrate the ability to use various technology platforms to ensure successful and timely referral connections are made.
• Effectively work in a hybrid work environment. Some local travel may be required for meetings, community events, and other job-related responsibilities.
• Demonstrate commitment to the values of diversity, equity, and inclusion.
• Extremely detail-oriented and capable of multitasking.
• Proficient computer skills and willingness to learn additional software applications.
• Demonstrated ability to thrive in a demanding environment.
• Must have a valid NYS driver’s license with a clean MVR.
• Preferred experience in supporting individuals with disabilities.
• Willingness to respond to the needs of a culturally diverse population.
• Ability to be seated and use computer equipment for several hours a day.

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