Job Description

Job Description

Job Description

Salary: $19.00 - $26.44

Job Title: Social Care Network (SCN) Community Health Worker

Project Summary:TheNew York State Department of Health has establishedSocial Care Networks (SCNs)as part of the1115 Waiver Demonstration Amendment, and Forward Leading IPA (FLIPA) is the SCN Lead for the Finger Lakes Region. This region is comprised of 14 counties, including Allegany, Cayuga, Chemung, Genesee, Livingston, Monroe, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, and Yates. The SCNs aim is to enhance the delivery of social care services toMedicaid membersby coordinating efforts amongcommunity-based organizations (CBOs) and other health care partners to create a more resilient, flexible, and accessible social care system that reduces health disparities and advances health equity. The SCN will collaborate with CBOs and other health care partners, leveraging shared data and technology to coordinate social care services for Medicaid members to improve access, ensure reliable and timely referrals, streamline and track navigation and completed referrals in closed loop systems and enhance collaboration between social care service providers and other regional partners.

Job Summary:
This position systematically identifies, assesses, refers, and monitors high-need individuals to ensure access to essential services. By building and maintaining key service connections, the Community Health Worker utilizes a screening tool to identify the health and social needs of Medicaid recipients. This role is pivotal in identifying individuals eligible for Enhanced Health-Related Social Needs (HRSN) Services, facilitating
appropriate referrals andensuring necessary linkages and support systems are in place.
This position is grant-funded through March 2027.

Additional information:

• This position will be primarily remote. However, given the nature of the role, approximately 50% of the workday is anticipated to include regular travel and in-community work within the Finger Lakes region for community convenings and relationship building. Occasional travel across New York State is also expected for on-site meetings or training.

• Residency within the Finger Lakes region of New York State is required.

Organizational Overview: Forward Leading IPA (FLIPA) is a nonprofit membership association of safety net providers working in partnership to provide the highest quality integrated healthcare to historically underserved populations in Upstate New York since 2017. FLIPA is renowned for its commitment to integrating primary care, behavioral health, and social care needs. Our growing membership serves individuals across Upstate NY and includes federally qualified health centers (FQHCs), behavioral health providers, and a rural health network consisting of eight county public health departments.

Duties/Responsibilities:

Client Services and Goal Achievement

• Engages directly with individuals seeking assistance.

• Administers the Health-Related Social Needs Screening Tool to identify needed areas of support.

• Short Term involvement with no ongoing caseload.

• Referral and Coordination:

• Facilitate referrals to appropriate community resources and healthcare providers.

• Collaborate with the Care Team to ensure timely follow-up and service linkage.

• Use online referral systems and databases to track and manage client referrals.

Client Advocacy and Support

• Advocate on behalf of clients to access necessary services and address barriers to care.

• Educate clients about available community resources and assist them in navigating healthcare and social service systems.

• Data Management and Reporting:

• Accurately document screening results, referrals, and client interactions in electronic systems.

• Maintain detailed and organized records in compliance with organizational policies and standards.

Collaboration and Team Integration

• Work closely with the Care Team, including care coordinators and other healthcare professionals, to ensure holistic client care.

• Participate in regular team meetings and contribute insights on client progress and community resources.

Community Outreach and Engagement

• Engage with community organizations to strengthen service networks and improve referral pathways.

• Represent the organization at community events and provide outreach to identify individuals in need of services.

• Provide information to community partners on mental health and substance use issues and resources.

• Build relationships with community organizations and service providers.

• Conduct outreach to identify individuals in need of services.

• Represent the organization at community events and stakeholder meetings.

• Other duties as assigned

Education & Experience:

• Minimum of High School Diploma or GED.

• Associate's degree in human services, Social Work or other related degree preferred.

• Equivalent experience in lieu of education may be considered.

• Minimum of 1-3 years' human services experience.

Skills, Knowledge, and Abilities:

• Possess excellent verbal and written communication skills.

• Exceptional customer service skills with commitment to helping others.

• Ability to quickly adapt and be flexible in approach to job tasks and challenges and maintain emotional control under stress.

• Excellent time management skills with exceptional attention to detail and the ability to multi-task and manage multiple priorities with competing deadlines.

• Capability to work cooperatively with culturally diverse clients, staff, and community service providers.

• Basic computer literacy, including the ability to use email, conduct online research, and create basic documents (MS Office Suite including Excel, Outlook and Word).

• NYS motor vehicle license, safe driving record and availability of personal vehicle for work.
• Holds self and others responsible and accountable to meet commitments

PayRange:

Hourly payrate is commensurate to education and experience with a range of
$18.26 - $26.44 per hour with a 40-hour work week.

Security Level: Standard - WLC

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