Community Health Worker

$44,990 - $44,990/Yr

Access Supports for Living - Middletown, NY

Full-time

Middletown, NY

About the position

The Community Health Worker (CHW) - Social Care Network Specialist plays a vital role in addressing health-related social needs (HRSN) as part of the New York State 1115 Medicaid waiver initiative. This position focuses on conducting comprehensive assessments, connecting individuals and families to community resources, and coordinating services through Social Care Networks (SCNs). The CHW serves as a trusted intermediary between healthcare systems, social care providers, and the communities they serve.

Responsibilities

• 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.
• Develop personalized action plans based on HRSN 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.
• 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.
• 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.
• Maintain accurate and detailed records of HRSN assessments, client interactions, and outcomes.
• Analyze data to identify trends, service gaps, and areas for improvement in addressing HRSN.
• Contribute to the evaluation of the SCN's impact on health outcomes and the 1115 waiver goals.
• 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 the development of educational materials to support client understanding of available services.

Requirements

• Strong organization skills with accurate attention to detail.
• Excellent communication skills and the ability to multi-task.
• Knowledgeable and skilled in understanding and educating others on healthcare, healthcare systems, healthcare reform, pathways to care, and communication with community providers.
• Experience conducting assessments, especially related to HRSN, in healthcare or social service settings.
• Familiarity with Medicaid programs, 1115 waiver initiatives, and SDOH frameworks.
• Excellent interpersonal, communication, and problem-solving skills.
• Proficiency with electronic data systems and referral platforms.
• Excellent verbal, written and presentation skills.

Nice-to-haves

• Bilingual or multilingual abilities preferred.