Social Care Navigator

Purpose : The Social Care Navigator will align his/her scope of work with Jawonio's Mission, while incorporating Jawonio's Core Values as the guiding principle for all work activities. The Social Care Navigator works independently or as part of a larger team to provide screenings, navigation of services and case management for eligible Medicaid enrollees as they relate to their social determinants of health needs. Bilingual/Spanish speaking required

Summary : The Social Care Navigator will operate within the framework of the Social Care Network, providing direct assistance to individuals to address Health-Related Social Needs (HRSN) and improve overall well-being. This role involves facilitating access to essential services such as housing, healthcare, nutrition, transportation, and other community resources. The Social Care Navigator collaborates closely with program members, and relevant service providers to identify and address social determinants of health, and implement a comprehensive array of support and services, improving health outcomes and quality of life.

This is a time-limited funded position for the duration of the project which is slated to end in 2027. Employment is expected to continue for the lifespan of the funded program.

Essential Duties and Responsibilities:

1. Assess a member's initial eligibility for Enhanced HRSN services following an SCN Screening that confirmed unmet Health Related Social Needs.
2. Conduct interim eligibility assessments to determine if a member has experienced a status change that results in eligibility changes for Enhanced HRSN or other services and inform the SCN Lead Entity and HRSN Service Providers of any needed changes to service delivery (e.g., the need to end services or change end of service delivery dates when a Member's Medicaid enrollment status changes).
3. Refer eligible members to appropriate Enhanced HRSN to meet their needs.
4. Collaborate with members eligible for Enhanced HRSN to establish goals and develop and implement an individualized Social Care Plan. Track members' progress in achieving the goals and desired outcomes outlined in their Social Care Plan.
5. Serve as a single point of contact for the Member and work with related health and social care providers, natural support, and/or advocates to execute the members' Social Care Plan and ensure seamless service delivery.
6. Update the Social Care Plan throughout services as needed and with notes helpful to support service coordination by health and social care professionals.
7. Assist members who are at the end of Enhanced HRSN service delivery to ensure service completion, identify persistent needs, and provide support in transitioning to additional support (e.g., existing community programs), where relevant and desired.
8. Assist members who are not eligible for/opt out of Enhanced HRSN services or need additional support beyond Enhanced HRSN services to access relevant existing communities and health care support and services. This includes providing one-on-one support to members such as Accompanying them to appointments and assisting with completion/collection of applications or other documents.
9. Utilize a closed-loop referral system to receive, track, and manage referrals to community services, and document member engagements and outcomes.
10. Maintain accurate case notes and other relevant documentation in compliance with SCN requirements and state and federal guidelines.
11. Advocate on behalf of members to address barriers to accessing care and services.
12. Attend and participate in regular team meetings, training, and development opportunities.
13. Comply with all STIC policies and procedures, as well as applicable state and federal laws, rules and regulations related to the Social Care Network and the 1115 Waiver.
14. Collect and maintain all required statistical and other data and prepare reports within established time limits.
15. Attend all mandatory agency and departmental trainings, meetings.

Spanish Speaker required

Education and Experience

1. High School Diploma required. Associate's degree in social work, Human Services, or a related field preferred.
2. One year experience in care management, social services preferred; or
3. An equivalent combination of education and experience.

Knowledge, Skills, and Abilities

1. Strong commitment to the independent living philosophy, Person Centered Planning, individual choice, and integration of people with disabilities into all aspects of community life.
2. The ability to effectively interact and work with individuals from diverse cultures and backgrounds.
3. Proficient in the use of all Microsoft Office applications (Excel, Word, Power Point).
4. Ability to communicate effectively, both verbally and in writing.
5. Demonstrate professional work habits including dependability, time management, independence, and responsibility.
6. Knowledge of ethical and professional responsibilities and boundaries.
7. Excellent attention to detail and organizational skills.
8. Ability to multi-task and work effectively in both a team and individual setting.
9. Capacity to work in various settings, including home visits and community-based locations.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally exposed to wet or humid conditions (non-weather); work near moving mechanical parts; fumes or airborne particles; toxic or caustic chemicals; risk of electrical shock and vibration. The noise level in the work environment is usually moderate.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include Close vision, Distance vision, Peripheral vision, and Ability to adjust focus. While performing the duties of this job, the employee is frequently required to walk and use hands to finger, handle, or feel. The employee is occasionally required to stand, sit; reach with hands and arms; stoop, kneel, crouch, or crawl; talk or hear and taste or smell.

Additional Requirements:

• Must be clear and maintain an acceptable record under the Medicaid Fraud & Abuse clearance process.
• Requires schedule to accommodate contract needs and requirements.
• Must remain clear with all OPWDD/OMH background checks.
• Must have an acceptable driving record.