SOCIAL CARE NAVIGATOR - Central Islip, NY

Suffolk, Inc.; Town of Islip (NY); On-site; USD 42,000 - 68,000; Full time

Job summary

Suffolk, Inc. is seeking a field-based Care Coordination Specialist to perform Health-Related Social Needs (HRSN) screenings and provide care management for Medicaid Managed Care members in New York.

The role involves using Unite Us to screen, assess needs, and connect clients with community resources. Responsibilities include developing individualized Social Care Plans, coordinating across transportation, housing, and utilities, and ensuring documentation complies with HEALI SCN guidelines.

Qualifications

• Demonstrated understanding of social determinants of health and experience addressing underserved populations.
• Proficient in case management platforms; familiarity with Unite Us is a plus.
• Strong communication and interpersonal skills to build trust with clients.
• Ability to work independently with minimal supervision and adapt to guidelines.
• Discretion handling sensitive information and maintaining confidentiality.
• Commitment to trauma-informed, person-centered care practices.

Responsibilities

• Conduct standardized screenings for Health-Related Social Needs (HRSNs) using the Unite Us screening tool.
• Provide care management services to Medicaid Managed Care members eligible for Enhanced HRSN Services.
• Coordinate access to community-based resources to address social determinants of health.
• Maintain accurate documentation and adhere to Medicaid and HEALI SCN requirements.
• Screen members annually or after major life events; obtain consent and verify eligibility.
• Develop and manage Social Care Plans, tracking referrals and outcomes in Unite Us.
• Collaborate with in-house and external providers to ensure timely service delivery.
• Follow up with members to assess satisfaction and service impact; document all notes.

Skills

Understanding of social determinants

Unite Us familiarity

Strong communication skills

Independent work

Discretion with sensitive information

Trauma-informed care

Education

High school diploma

Tools

Unite Us

Case management platforms

Job description

Description

MAJOR RESPONSIBILITIES:

• Conduct standardized screenings for Health-Related Social Needs (HRSNs) using the Unite Us screening tool.
• Provide care management services to Medicaid Managed Care members eligible for Enhanced HRSN Services.
• Coordinate access to community-based resources and services to address social determinants of health.
• Maintain accurate documentation and adhere to Medicaid and HEALI SCN program requirements.

DETAILED RESPONSIBILITIES:

HRSN Screening:

• Use the Unite Us IT platform to administer the HRSN screening tool via the phone
• Screen Medicaid members annually or after major life events (e.g., hospitalization, loss of benefits, change in housing).
• Obtain member consent, verify Medicaid eligibility, and confirm enrollment in Social Care Coverage.
• Ensure screenings are conducted in a private, secure setting and assess whether follow-up care or navigation is needed.
• Educate members on the purpose and outcome of screenings and assist in identifying next steps for support.

Enhanced HRSN Services Care Management:

• Conduct Eligibility Assessments for Medicaid Managed Care members via the phone to determine qualification for Enhanced HRSN Services.
• Develop and manage individualized Social Care Plans, tracking referrals and outcomes in Unite Us.
• Coordinate services across multiple domains, including but not limited to transportation, utility assistance, home safety modifications, temporary housing, and cooking supply delivery.
• Collaborate with in house EOC program and external providers to ensure service delivery within designated timelines.
• Conduct follow-up with members to assess satisfaction and service impact and need for additional referrals.
• Document all case notes, outreach attempts, and service updates according to HEALI SCN guidelines.

QUALIFICATIONS:

• Demonstrated understanding of social determinants of health and experience addressing the needs of underserved populations.
• Proficient in using case management platforms; familiarity with Unite Us is a plus.
• Strong communication and interpersonal skills to build trust and rapport with clients.
• Ability to work independently with minimal supervision, manage time effectively, and adapt to evolving program guidelines.
• Capable of handling sensitive information with discretion and maintaining client confidentiality.
• Committed to trauma-informed, person-centered care practices.

EDUCATION/TRAINING/EXPERIENCE:

• High school diploma
• Minimum of 2 years of experience in care coordination, case management, social services, or a related setting.
• Prior experience working with Medicaid populations or community-based health program preferred in

Requirements

• A Valid Driver's License and Insured Vehicle.
• PPD (TB test required with proof of results; no more than 1 year old)