MAJOR RESPONSIBILITIES:

· Conduct standardized screenings for Health-Related Social Needs (HRSNs) using the Unite Us screening tool.

· Provide care management services to Medicaid Managed Care members eligible for Enhanced HRSN Services.

· Coordinate access to community-based resources and services to address social determinants of health.

· Maintain accurate documentation and adhere to Medicaid and HEALI SCN program requirements.

DETAILED RESPONSIBILITES:

HRSN Screening:

· Use the Unite Us IT platform to administer the HRSN screening tool via the phone 

· Screen Medicaid members annually or after major life events (e.g., hospitalization, loss of benefits, change in housing).

· Obtain member consent, verify Medicaid eligibility, and confirm enrollment in Social Care Coverage.

· Ensure screenings are conducted in a private, secure setting and assess whether follow-up care or navigation is needed.

· Educate members on the purpose and outcome of screenings and assist in identifying next steps for support.

Enhanced HRSN Services Care Management:

· Conduct Eligibility Assessments for Medicaid Managed Care members via the phone to determine qualification for Enhanced HRSN Services.

· Develop and manage individualized Social Care Plans, tracking referrals and outcomes in Unite Us.

· Coordinate services across multiple domains, including but not limited to transportation, utility assistance, home safety modifications, temporary housing, and cooking supply delivery.

· Collaborate with in house EOC program and external providers to ensure service delivery within designated timelines.

· Conduct follow-up with members to assess satisfaction, service impact, and need for additional referrals.

· Document all case notes, outreach attempts, and service updates according to HEALI SCN guidelines.

QUALIFICATIONS: 

· Demonstrated understanding of social determinants of health and experience addressing the needs of underserved populations.

· Proficient in using case management platforms; familiarity with Unite Us is a plus.

· Strong communication and interpersonal skills to build trust and rapport with clients.

· Ability to work independently with minimal supervision, manage time effectively, and adapt to evolving program guidelines.

· Capable of handling sensitive information with discretion and maintaining client confidentiality.

· Committed to trauma-informed, person-centered care practices.

EDUCATION/TRAINING/EXPERIENCE:

· High school diploma 

· Minimum of 2 years of experience in care coordination, case management, social services, or a related setting.

· Prior experience working with Medicaid populations or community-based health programs preferred.

· Bilingual in English and Spanish

· Completion of HEALI SCN training(s) required upon hire

• A Valid Driver's License and Insured Vehicle.
• PPD (TB test required with proof of results; no more than 1 year old)