Social Care Navigator

POSITION SUMMARY
The Social Care Navigator I (SCN) is the front line of NYREACH’s Social Care Network, connecting
Medicaid members to the social care services they need to thrive. The SCN conducts outreach, screens
members for health-related social needs (HRSN) — including housing, food insecurity, transportation,
and interpersonal safety — assesses eligibility for enhanced HRSN services, and provides hands-on
navigation and closed-loop referrals to community-based resources. The SCN builds trusted relationships
with members and follows each referral through to completion, ensuring members do not fall through the
cracks between screening and service delivery.
In addition to core screening and navigation responsibilities, this SCN position carries a special focus on
nutritional health, supporting members in accessing healthy food resources and nutrition-related services.
Ideal candidates possess strong communication and interpersonal skills, a passion for helping others, deep
familiarity with community resources, and experience in social services, community health, or care
navigation.
KEY RESPONSIBILITIES
HRSN Screening & Eligibility Assessment
● Conduct proactive outreach to Medicaid members telephonically, in person, and in community
settings to engage them in social care services.
● Administer HRSN screenings to identify unmet social needs across domains including housing
stability, food insecurity, transportation, and interpersonal safety.
● Assess and document member eligibility for enhanced HRSN services in accordance with Social Care
Network protocols.
● Build rapport and trust with members, meeting them where they are and applying a person-centered,
trauma-informed approach.
Navigation & Closed-Loop Referrals
● Connect members with appropriate community resources, including social service agencies,
community-based organizations, healthcare providers, and government benefit programs.
● Facilitate referrals to social care services, track each referral through to completion, and follow up
with members and providers to confirm needs were addressed (closed-loop referral management).
● Provide ongoing navigation support to members with complex or multiple needs, escalating and rereferring as circumstances change.
● Collaborate with team members, partner-based navigators/CHWs, and community partners to
coordinate care for members with complex needs and ensure seamless service delivery.
Documentation & Community Partnership
● Use technology platforms to document member eligibility, outreach activities, case notes, referral
outcomes, and other required data, adhering to established protocols and confidentiality standards.
● Maintain accurate, timely records of all interactions, referrals, and outcomes.
● Represent NYREACH at community events and cultivate working relationships with community
organizations, partners, and healthcare facilities to strengthen the local resource network.
● Perform other tasks assigned by the Senior Director of NYREACH.
Nutrition Focus: Education & Access
● Manage a caseload of assigned members with nutrition-related needs, connecting them to healthy
food resources such as food pantries, benefits programs, medically tailored meals, and nutrition
services.
● Conduct workshops, seminars, one-on-one consultations, and presentations on healthy eating habits,
disease prevention, and nutrition topics.
● Provide personalized nutrition education to individuals and groups, focusing on healthy eating habits,
meal planning, portion control, food preparation, and the impact of nutrition on overall health.
PERFORMANCE EXPECTATIONS
● Meet or exceed monthly HRSN screening and outreach targets as established by program leadership.
● Achieve and maintain a closed-loop referral completion rate consistent with program benchmarks,
ensuring members are connected to and confirmed as having received referred services.
● Complete all required documentation within established timeframes (same-day entry required for all
screenings and referrals).
● Maintain an active caseload of members with nutrition-related needs and deliver nutrition education
sessions, workshops, or consultations on a consistent, ongoing basis.
● Actively represent NYREACH at community events and maintain productive, ongoing relationships
with partner organizations and healthcare facilities.
● Maintain professionalism, accuracy, and member-centered communication standards in all
interactions.
REQUIRED QUALIFICATIONS
● High school diploma or GED required.
● Experience in social services, community health, care navigation, or a related field; familiarity with
community resources and benefit programs.
● Strong communication, interpersonal, and organizational skills; effective verbal and written
communication is essential for interacting with members, providers, and other stakeholders.
● Cultural sensitivity and the ability to adapt to different needs and work with a diverse population.
● Comfort using technology platforms for screening, referrals, and documentation.
● Bilingual Spanish required.
PREFERRED QUALIFICATIONS
● Associate’s or Bachelor’s degree in social work, human services, public health, community health,
nutrition, or a related field.
● Background in nutrition, dietetics, or community nutrition.
● Experience with HRSN screening, closed-loop referral platforms, or Medicaid populations.
● Community Health Worker (CHW) training or lived experience in the communities served.
WORK ENVIRONMENT
● This is a full-time, field-based position. Remote or fully in-office arrangements are not available for
this role.
● This position requires regular fieldwork and local travel to community events, partner organizations,
healthcare facilities, and other assigned locations throughout the service area.
● Employees are responsible for travel between locations.
● Setting up for community events (e.g., tables, tents, and outreach materials) may require long periods
of standing and light to moderate lifting.
● Direct work with members in person, over the phone, and through other communication methods.