Social Care Screener

Primary Duties & Essential Functions:

• Engage Medicaid members in person, telephonically, or virtually to discuss screening, complete screening and determine eligibility to address health-related social needs using a person-centered, culturally responsive, and trauma-informed approach.
• Confirm eligibility for services, utilizing Epaces to ensure insurance is active and billable.
• Coordinate screening and eligibility assessment with the individuals and document status of completion of to meet health-related social needs, including but not limited to housing instability, food insecurity, transportation barriers, utility needs, and interpersonal safety.
• Ensure all documentation supports service verification, encounter reporting, utilization review, and audit validation. 
• Complete NY1115 - AHC Screening.
• Complete Eligibility Assessment, confirm eligibility. If eligible, open Social Service Case Management refer to Social Care Navigator and create service note for work completed for billing.
• Work closely with Social Care Navigator and Assistant Director regarding status of referrals, service plans, billing, etc.  
• Collaborate with care managers, peer advocates, and clinical teams to support integrated care planning and continuity of care.
• Monitor and track weekly number of individuals receiving SDOH Care Screening services and SDOH Case Management services (name of individual, date of screening, date of assessment, level: 1 or 2, etc.).
• Participate in quality assurance, data validation, and utilization monitoring activities related to 1115 Waiver reporting.
• Support internal reviews, corrective action plans, and external monitoring or audit requests assigned. 
• Maintain confidentiality and comply with HIPAA, Medicaid, and DOH data privacy and security requirements.
• Attend required training related to DOH guidance, waiver updates, reporting requirements, and program compliance.
• Participate in supervision, team meetings, and case conferences as required.
• Perform other duties as assigned in support of DOH and 1115 Waiver program objectives.
• Meet billables weekly to ensure viability of program (5 screenings and assessments daily).  

Required Education, Knowledge, and Skills:

•  Associate’s degree in human services, public health, social work, or related field bachelor's degree preferred.
• Experience in case coordination, care navigation, outreach, or direct service provision with Medicaid or underserved populations.
• Knowledge of SDOH/HRSN concepts and community-based service systems.
• Ability to follow standardized protocols for screening, assessing, referring, documentation, and follow-up.
• Demonstrated ability to maintain accurate, timely, and compliant records. 
• Proficiency with electronic health records and/or DOH-aligned reporting systems.
• Strong organizational, communication, and interpersonal skills.

Preferred Qualifications:

• Experience with NYS DOH programs, Health Homes, Managed Care, PPS initiatives, or 1115 Waiver services.

• Familiarity with DOH guidance, Medicaid documentation standards, and audit processes. 
• Experience using referral tracking platforms or community resource databases. 
• Bilingual or multilingual proficiency.

Abilities and Working Conditions:

• Adherence to DOH guidance, Medicaid regulations, and 1115 Waiver service requirements is mandatory.

• All case coordination, screening, referral, and follow-up activities must be documented accurately to support reporting, utilization monitoring, and audit review.

• Staff are expected to cooperate with internal and external quality assurance, monitoring, and audit activities.
• Willingness to respond to the needs of a culturally diverse population.
• Ability to be seated and use computer equipment for several hours a day.

Vanderheyden is committed to the National Sanctuary Model - a blueprint for clinical and organizational change which, at its core, promotes safety and recovery from adversity through the active creation of a trauma-informed community.  The Sanctuary Model's focus is not only on the people who seek services, but equally on the people and systems that provide those services.

As an Equal Opportunity Employer, does not discriminate in its hiring or employment practices on the basis of gender, race or ethnicity, color, national origin, religion, age, disability, military or marital status, sexual orientation, gender identity or expression, domestic violence victim status, predisposing genetic characteristics or prior arrest or conviction record or any other category protected by applicable federal, state, or local laws