Access: Supports for Living
Location:
Mt. Vernon, NY
Hours:
Monday–Friday, Flexible
Rate:
$24.04 per hour
Seniority level:
Entry Level
Employment type:
Full‑time
Overview of Primary Responsibilities The Community Health Worker (CHW) – Social Care Network Specialist plays a key role in advancing the New York State 1115 Medicaid waiver’s focus on addressing health‑related social needs (HRSN). This role emphasizes conducting comprehensive HRSN assessments, connecting individuals and families to community resources, and coordinating services through Social Care Networks (SCNs). The CHW acts as a trusted bridge between healthcare systems, social care providers, and the communities served.
Health‑Related Social Needs (HRSN) Assessments
Conduct thorough HRSN assessments to identify barriers to health such as housing instability, food insecurity, transportation challenges, and lack of access to social services.
Use standardized tools and evidence‑based practices to evaluate client needs and strengths.
Prioritize outreach to Medicaid members with complex needs or at high risk for poor health outcomes.
Client Support and Navigation
Develop personalized action plans based on assessment findings.
Provide direct support to clients in accessing community resources and overcoming systemic barriers.
Offer culturally competent education on available services and empower clients to advocate for their needs.
Referral Coordination within Social Care Networks (SCNs)
Leverage SCN platforms (Unite Us) to initiate and track referrals.
Work closely with SCN partners to ensure timely and effective service delivery.
Monitor and document referral outcomes, ensuring clients’ needs are adequately addressed.
Collaboration with Healthcare Providers and Community Stakeholders
Partner with managed care organizations (MCOs), healthcare providers, and community‑based organizations (CBOs) to integrate social and healthcare services.
Facilitate communication between clients and medical providers, ensuring HRSN are addressed alongside clinical care.
Participate in care team meetings to share assessment findings and collaborate on care coordination.
Field‑based role involving home visits, community outreach, and coordination with local agencies.
Data Collection and Reporting
Maintain accurate and detailed records of HRSN assessments, client interactions, and outcomes.
Analyze data to identify trends, service gaps, and areas for improvement.
Contribute to the evaluation of the SCN’s impact on health outcomes and the 1115 waiver goals.
Community Engagement and Capacity Building
Build partnerships with community leaders and organizations to expand access to resources.
Educate stakeholders about the importance of HRSN and the integration of social and healthcare services.
Assist in developing educational materials to support client understanding of available services.
Qualifications and Attributes
Strong organizational skills with accurate attention to detail.
Excellent communication skills and ability to multitask.
Experience conducting HRSN assessments in healthcare or social service settings.
Knowledge of Medicaid programs, 1115 waiver initiatives, and SDOH frameworks.
Excellent interpersonal, problem‑solving, and presentation skills.
Proficiency with electronic data systems and referral platforms.
Bilingual or multilingual abilities preferred.
Education and Experience
High school diploma or equivalent required.
Associate or bachelor’s degree in social work, public health, or related field preferred.
Completion of a recognized Community Health Worker training program preferred.
Physical Characteristics
Capable of sitting or standing in front of a computer for long periods.
Able to work in an open‑space floor plan.
Capable of moving throughout the workday and interacting with community members.
Work alongside co‑workers within 3 feet.
Occasional lifting of > 25 pounds.
EEO Statement:
This organization is an equal‑opportunity employer and encourages applicants from all backgrounds.
#J-18808-Ljbffr
Mt. Vernon, NY
Hours:
Monday–Friday, Flexible
Rate:
$24.04 per hour
Seniority level:
Entry Level
Employment type:
Full‑time
Overview of Primary Responsibilities The Community Health Worker (CHW) – Social Care Network Specialist plays a key role in advancing the New York State 1115 Medicaid waiver’s focus on addressing health‑related social needs (HRSN). This role emphasizes conducting comprehensive HRSN assessments, connecting individuals and families to community resources, and coordinating services through Social Care Networks (SCNs). The CHW acts as a trusted bridge between healthcare systems, social care providers, and the communities served.
Health‑Related Social Needs (HRSN) Assessments
Conduct thorough HRSN assessments to identify barriers to health such as housing instability, food insecurity, transportation challenges, and lack of access to social services.
Use standardized tools and evidence‑based practices to evaluate client needs and strengths.
Prioritize outreach to Medicaid members with complex needs or at high risk for poor health outcomes.
Client Support and Navigation
Develop personalized action plans based on assessment findings.
Provide direct support to clients in accessing community resources and overcoming systemic barriers.
Offer culturally competent education on available services and empower clients to advocate for their needs.
Referral Coordination within Social Care Networks (SCNs)
Leverage SCN platforms (Unite Us) to initiate and track referrals.
Work closely with SCN partners to ensure timely and effective service delivery.
Monitor and document referral outcomes, ensuring clients’ needs are adequately addressed.
Collaboration with Healthcare Providers and Community Stakeholders
Partner with managed care organizations (MCOs), healthcare providers, and community‑based organizations (CBOs) to integrate social and healthcare services.
Facilitate communication between clients and medical providers, ensuring HRSN are addressed alongside clinical care.
Participate in care team meetings to share assessment findings and collaborate on care coordination.
Field‑based role involving home visits, community outreach, and coordination with local agencies.
Data Collection and Reporting
Maintain accurate and detailed records of HRSN assessments, client interactions, and outcomes.
Analyze data to identify trends, service gaps, and areas for improvement.
Contribute to the evaluation of the SCN’s impact on health outcomes and the 1115 waiver goals.
Community Engagement and Capacity Building
Build partnerships with community leaders and organizations to expand access to resources.
Educate stakeholders about the importance of HRSN and the integration of social and healthcare services.
Assist in developing educational materials to support client understanding of available services.
Qualifications and Attributes
Strong organizational skills with accurate attention to detail.
Excellent communication skills and ability to multitask.
Experience conducting HRSN assessments in healthcare or social service settings.
Knowledge of Medicaid programs, 1115 waiver initiatives, and SDOH frameworks.
Excellent interpersonal, problem‑solving, and presentation skills.
Proficiency with electronic data systems and referral platforms.
Bilingual or multilingual abilities preferred.
Education and Experience
High school diploma or equivalent required.
Associate or bachelor’s degree in social work, public health, or related field preferred.
Completion of a recognized Community Health Worker training program preferred.
Physical Characteristics
Capable of sitting or standing in front of a computer for long periods.
Able to work in an open‑space floor plan.
Capable of moving throughout the workday and interacting with community members.
Work alongside co‑workers within 3 feet.
Occasional lifting of > 25 pounds.
EEO Statement:
This organization is an equal‑opportunity employer and encourages applicants from all backgrounds.
#J-18808-Ljbffr