Social Care Navigator: Care Coordination & HRSN Support

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

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