Social Care Network Navigator & Diversion Specialist

Job Description

Job Description

Description:

Title: Social Care Network Navigator & Diversion Specialist

Position Type: Full-time, Non-exempt

Reports to: Middletown Program Manager

Base Location: Middletown

Schedule: Monday - Friday 9am-5pm

Pay Rate: $25.00/hr

About Independent Living, Inc.

Since 1987, Independent Living, Inc. (ILI) has been increasing access, encouraging self-determination, and advocating for the rights of people with disabilities throughout the Hudson Valley of New York. Following the traditional independent living center (ILC) model, the majority of ILI’s board and staff are individuals with disabilities, bringing valuable peer and life-experience perspectives to the services we provide.

ILI is committed to empowering individuals to live independently and participate fully in their communities.

Interested in learning more about who we are? We encourage applicants to watch our agency video to gain insight into our mission, vision, values, and the impact we make within the community. The video offers a closer look at our culture and the meaningful work our team does every day. Please select the link below for your preferred platform to view the video.

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Why Work with Us?

• Join a mission-driven organization dedicated to building a barrier-free society and supporting independent living
• Be part of a collaborative workplace that embraces diversity and innovation, where every team member’s voice and lived experience are respected and valued
• Be part of an organization that champions inclusive hiring practices and actively welcomes individuals of all abilities, recognizing the value of both visible and non-visible disabilities
• Help improve health outcomes by addressing health-related social needs and connecting individuals to critical community resources.
• Build meaningful relationships with hospitals, behavioral health providers, emergency responders, and community organizations to strengthen community-based care.
• Make a lasting impact by empowering individuals to achieve greater independence, wellness, and long-term stability.

About the Role

The Social Care Network Navigator & Diversion Specialist plays a vital role in improving health outcomes by connecting individuals with health-related social needs, behavioral health concerns, housing instability, substance use challenges, and other barriers to community living with appropriate supports and services.

Working in both hospital and community settings, this position conducts screenings, determines eligibility for services, provides recovery-oriented peer support, and coordinates referrals through the Social Care Network (SCN) and other community-based resources. The Social Care Network Navigator & Diversion Specialist serves as a compassionate advocate, helping individuals navigate complex systems of care while promoting self-determination, reducing unnecessary hospitalizations, and strengthening connections to community supports.

What You'll Do

• Conduct comprehensive health-related social needs screenings, benefits eligibility assessments, and contracted service assessments using approved SCN screening tools.
• Accept and manage referrals through UniteUs and other referral platforms, ensuring timely outreach, engagement, and follow-up.
• Provide outreach and navigation services to Medicaid populations in hospitals, emergency departments, and community settings.
• Conduct Screenings, Navigation and Contracted Services from the Emergency Department at St. Lukes Montefiore in Newburgh on a rotating basis 2-3 days a week and in other community settings as needed.
• Assess participant eligibility for available services and coordinate referrals to appropriate community-based organizations and supports.
• Provide peer-based support, encouragement, advocacy, and recovery-oriented coaching to individuals experiencing mental health challenges, substance use concerns, housing instability, social isolation, or other life challenges.
• Support individuals in developing recovery plans, wellness strategies, psychiatric advance directives, and other person-centered goals that promote independence and self-determination.
• Collaborate with hospitals, mobile crisis teams, behavioral health providers, law enforcement agencies, care managers, and community organizations to coordinate services and improve continuity of care.
• Follow up with participants to ensure referrals have been successfully completed, and health-related social needs have been addressed.
• Maintain current knowledge of SCN services, community resources, Medicaid programs, behavioral health services, housing supports, and disability-related resources.
• Advocate for participants by helping them overcome barriers, access services, strengthen self-advocacy skills, and navigate complex service systems.
• Document all outreach activities, screenings, referrals, follow-up services, and participant interactions accurately in UniteUs, Foothold, and other required databases.
• Work collaboratively with program leadership to improve workflows, identify service gaps, and implement quality improvement initiatives.
• Prepare participant success stories and outcome summaries that demonstrate program impact.
• Complete all required reports, maintain accurate records, and participate in required meetings, supervision, trainings, and hospital onboarding activities.
• Perform other duties as assigned to support program operations.

The Ideal Candidate Will Have

• High School Diploma or GED.
• Must complete all required Hudson Valley Care Coalition (HVCC) Social Care Network screening and navigation training during the first week of employment.
• Must successfully complete all required hospital and other partnership onboarding requirements, including medical clearances, trainings, and compliance requirements necessary to provide services in those settings.
• Demonstrated ability to assess individual needs and connect participants with appropriate community resources and disability-related services.
• Lived experience with mental health recovery, substance use recovery, homelessness, disability, or other life challenges and a desire to use those experiences to support others is strongly encouraged.
• Strong understanding of person-centered, trauma-informed, and recovery-oriented service delivery.
• Excellent communication, interpersonal, and advocacy skills with the ability to build trust across diverse populations.
• Knowledge of community resources, disability services, behavioral health systems, housing supports, and social service programs.
• Strong organizational, documentation, time management, and problem-solving skills with the ability to work independently.
• Basic computer proficiency and the ability to navigate electronic referral systems, databases, and case management software.
• Must possess a valid, unrestricted driver's license and reliable transportation.

It Would Be a Plus If You Also Have

• Experience working within social services, healthcare navigation, behavioral health, care coordination, peer support, or community outreach programs.
• Certified Recovery Peer Advocate (CRPA) credential.
• NYCPS (New York Certified Peer Specialist) certification.
• Familiarity with UniteUs, Foothold, or similar case management and referral platforms.
• Knowledge of Medicaid populations, Health-Related Social Needs (HRSN), and Social Care Network initiatives.
• Bachelor’s degree in human services, Social Work, Psychology, Public Health, or a related field.
• Bilingual English/Spanish skills or proficiency in American Sign Language (ASL).
• Established knowledge of local behavioral health, housing, disability, and community support resources.

Success in This Role Will Be Demonstrated Through

• Successfully engaging individuals and building trusting, recovery-oriented relationships.
• Completing timely screenings, eligibility determinations, referrals, and follow-up activities while meeting Social Care Network performance expectations.
• Connecting participants with appropriate community-based services that improve health outcomes and address health-related social needs.
• Helping reduce unnecessary emergency department utilization, hospitalizations, and behavioral health crises through effective diversion and community engagement.
• Supporting individuals in achieving greater independence, wellness, recovery, and self-advocacy.
• Maintaining accurate, timely documentation and high-quality case records in all required systems.
• Building strong collaborative relationships with hospitals, community providers, behavioral health partners, and other stakeholders.
• Demonstrating professionalism, compassion, accountability, and a commitment to person-centered, trauma-informed, and recovery-oriented care in every interaction.

Benefits available to you include

• Paid holidays from the first day of employment
• Paid lunch break
• Paid time off
• 401(k) with company match
• Health, Dental and Vision insurance
• Flexible Spending Accounts (FSA)
• Company provided Life, AD&D and Short- and Long-Term disability insurance
• Voluntary insurances including Critical Illness and Hospital Indemnity

We actively support an inclusive hiring process and encourage people with disabilities, visible and non-visible, to apply. If you require reasonable accommodation to support the application or onboarding process, please contact Latoya Merricks at View phone number on ziprecruiter.com.

ILI is proud to be an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability status, veteran status, or any other characteristic or status protected by applicable law.

To apply, visit us at