Social Care Network Screener Navigator

SCN Screener/Navigator Position Summary

The Social Care Network Screener/Navigator is responsible for conducting screenings related to social determinants of health (SDH) and providing individualized navigation support to connect community members to resources and services. This position supports EPIC’s role in the Western New York Integrated Care Collaborative (WNYICC) and plays a key role in improving outcomes by removing barriers, enhancing access to care, and promoting self-sufficiency for individuals and families.

• Conduct empathetic and culturally competent screenings for social needs in-person, virtually, and/or telephonically.
• Manage daily screening intake and referrals, including follow-up calls, eligibility verification, and intake documentation.
• Triage and route referrals to the most appropriate community-based organizations or providers.
• Maintain accurate and timely documentation using the WNY Integrated Care IT platform.
• Provide in-home assessments as needed to support screening and service navigation.
• Maintain ongoing communication with referred clients and partner organizations to confirm connection or redirect referrals if needed.
• Provide exceptional customer service and support to individuals from a variety of cultural and socioeconomic backgrounds.
• Attend the WNYICC Screening/Navigation Workgroup and other relevant meetings.
• Comply with all HIPAA guidelines and applicable federal, state, and local privacy policies.
• Support continuous improvement of user experience within EPIC’s screening and navigation systems.
• Provide assessment eligibility as needed.
• Offer ongoing support to clients, addressing questions, concerns, and any issues that arise during screening.
• Maintain up to date working knowledge of all EPIC programming and services.

• Provide one-on-one navigation support to address clients’ unmet social needs (e.g., housing, food, employment, childcare, transportation).
• Work collaboratively with individuals to develop action plans and goals based on their priorities.
• Coordinate warm handoffs and support clients through service enrollment or application processes.
• Track and follow up on referrals to confirm outcomes and adjust plans if needed.
• Advocate on behalf of clients when barriers to access arise.
• Conduct in-home or community-based visits as appropriate.
• Offer support during critical transitions (e.g., housing move-in, new benefits, job search).
• Support financial stability efforts, including budget guidance and connection to income supports.
• Maintain an updated roster of community resources and maintain relationships with service providers.

• Maintain accurate records of deliverables, client interactions, assessments, and outcomes.
• Collect and report data related to outreach efforts, program enrollment, outcomes, and client feedback to track program effectiveness and improve services.
• Contribute to program evaluations and assist with preparing reports as required by funding agencies or organizational leadership.
• Maintain reporting requirements, data entry, evaluation forms, and other contract requirements.
• Prepare billing for finance as required.
• Work with the Finance department on policies and procedures.
• Other relevant duties as assigned by management.

• Strong personal initiative to motivate participants.
• Strong communication skills to convey neutrality and supportiveness.
• Strong initiative and ability to build trust with participants.
• Effective communication, organizational, and problem-solving skills.
• Experience working with individuals from diverse backgrounds.
• Strengths-based, trauma-informed, and harm-reduction approaches to service delivery.
• Comfort discussing sensitive topics and navigating crisis situations.
• Proficiency in Microsoft Office, Salesforce, and online research tools.
• Familiarity with social services systems, housing supports, and Medicaid populations preferred.
• Strong attention to detail, organizational skills.
• Strong ability to multitask and meet deadlines.
• Confidence speaking during needs assessment consultations and in group settings.
• Effectively build and maintain external and…