Social Care Network / Community Health Worker

Title: Social Care Network (SCN) Community Health Worker- This position is a hybrid position

Reports to: Care Coordination Program Supervisor

Job Objectives:

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 NON-Health-Related Social Needs (HRSN) Services, facilitating appropriate referrals, and ensuring necessary linkages and support systems are in place. This position is grant-funded through March 2027.

Responsibilities:

· Engages directly with individuals seeking assistance.

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

· Facilitate referrals to appropriate community resources and healthcare providers.

· Provide ongoing support to individuals until appropriate resources are secured and their identified needs have been addressed.

· 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.

· 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.

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

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

· 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.

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

· Build relationships with community organizations and service providers.

· Conduct outreach to identify individuals in need of services.

· Provide occasional in-person support to clients when necessary.

Represent MHA at meetings as necessary