Social Care Network Care Manager

Job Summary: The Social Care Network (SCN) Case Manager plays a critical role in advancing integrated, person-centered care through the Social Care Network. This position is responsible for addressing Health-Related Social Needs (HRSN) and Social Determinants of Health (SDOH) by coordinating services across healthcare, behavioral health, and community-based systems.

The SCN Case Manager ensures individuals—particularly those with complex medical, behavioral health, and social needs—are effectively connected to essential supports such as housing, food, transportation, and other stabilizing services. This role emphasizes whole-person care, health equity, and improved outcomes through cross-sector collaboration and data-informed service delivery.

Duties

1. Conduct comprehensive assessments to identify medical, behavioral health, and social care needs, including screening for HRSN/SDOH
2. Coordinate and facilitate access to SCN services, including housing supports, nutrition services, transportation, and other community-based interventions
3. Serve as a liaison between healthcare providers, community-based organizations (CBOs), and social care partners to ensure seamless service delivery
4. Develop and implement individualized, person-centered care plans that address both clinical and social needs
5. Support individuals in navigating systems of care and building skills to sustain long-term stability and independence
6. Monitor progress and adjust care plans based on outcomes and evolving needs
7. Maintain strong knowledge of local and regional SCN providers and resources
8. Actively engage community partners to expand access and reduce service gaps
9. Assist individuals in obtaining essential resources including housing, employment, transportation, food security, and healthcare access
10. Complete timely and accurate documentation in electronic health records and SCN platforms
11. Track and report on service utilization, referrals, and outcomes related to SCN interventions
12. Support quality improvement efforts by monitoring performance measures, including engagement, satisfaction, and health outcomes
13. Facilitate communication across multidisciplinary teams, including medical, behavioral health, and social care providers
14. Participate in case conferences and care coordination meetings
15. Utilize telehealth and digital platforms to enhance access and coordination
16. Ensure all services are delivered in compliance with FLACRA, Medicaid, and SCN requirements
17. Promote best practices in integrated care and uphold standards related to confidentiality, safety, and ethical care delivery