Social Care Navigator ; Bilingual-Spanish

Social Care Navigator I

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.

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 re-referring 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.

Required Qualifications:

• Bachelor's degree in social work, human services, public health, community health, nutrition, or a related field.

• 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…