Social Care Navigatgor (SCN)

TruCare_SCN_Navigator_Job_Description.pdf

POSITION SUMMARY

The Social Care Navigator performs three reimbursable functions under New York State’s Social

Care Network (SCN) program, which TruCare Connections operates through its subcontract with

Healthy Alliance Foundation:

1. HRSN Screening — Administering the NYS standardized AHC HRSN Screening Tool to identify unmet social needs in housing, nutrition, transportation, employment, education, and interpersonal safety.
2. Social Care Navigation — Conducting Eligibility Assessments, developing Social Care Plans, issuing and managing closed-loop referrals in Unite Us, and connecting members to HRSN service providers.
3. Enhanced Care Management — Providing intensive coordination for high-risk and Enhanced
4. Population members (Health Home enrollees, high utilizers, pregnant/postpartum, SMI, SUD,
5. IDD, criminal justice-involved).

KEY RESPONSIBILITIES

A. Screening

1. Administer the NYS AHC HRSN Screening Tool to Medicaid FFS and Managed Care (MMC) members annually and upon identified major life events (e.g., hospitalization, housing loss, incarceration, income change, birth/loss of family member).
2. Collect required member demographic information during each screening encounter.
3. Screen across all six HRSN domains: housing and utilities, food/nutrition, transportation, employment, education, and interpersonal safety.
4. Complete all required data fields in Unite Us for every screening; incomplete screenings are not billable.
5. Recognize and document major life events that trigger re-screening eligibility.
6. Conduct off-platform screenings per NYeC guidance and upload results to Unite Us within required timeframes.

B. Social Care Navigation

1. For members with positive screens, conduct a full Eligibility Assessment (EA) in Unite Us to determine eligibility for Enhanced HRSN Services (housing, nutrition, transportation, enhanced care management).
2. Use the Enhanced Services Member File (ESMF) — received monthly via Unite Us —alongside EA findings to determine applicable Enhanced HRSN Service eligibility; assess relevant Social Risk Factors for each identified unmet need.
3. Verify Medicaid Managed Care enrollment in real time using MEVS/ePACES prior to Enhanced HRSN Service referral.
4. Navigate Medicaid FFS members to existing federal, state, and local resources; FFS members are not eligible for Enhanced HRSN Services.
5. Issue closed-loop referrals in Unite Us: connect eligible MMC members to HRSN service providers in the Healthy Alliance network, track referral status, and follow up to confirm service delivery.
6. Manage service duplication checks; coordinate with MCO case managers when potentially duplicative services are identified; document duplication check activity under Enhanced Care Management billing.
7. Update member addresses and transfer workflows when members relocate across SCN regions.

C. Social Care Plans

1. Develop and maintain a Social Care Plan in Unite Us for each member receiving Enhanced HRSN Services; plans are longitudinal and must be revisited and updated as services are rendered and needs are met.
2. Ensure Social Care Plans reflect member-identified goals, household considerations, and relevant Social Risk Factors.
3. Coordinate re-authorizations for services approaching or exceeding initial service duration limits.

D. Enhanced Care Management

1. Provide intensive social care coordination for members belonging to Enhanced Populations: Medicaid High Utilizers, NYS Health Home enrollees, pregnant and postpartum persons, criminal justice-involved individuals with chronic or behavioral health conditions, high-risk children under 18, and persons with IDD, SMI, or SUD.
2. Conduct multi-program service duplication checks and MCO contact outreach; bill coordination time under Enhanced Care Management as directed by Healthy Alliance billing protocols.
3. Liaise with Health Home care managers (including TruCare’s own CM team) when members are dually enrolled, to ensure coordinated — not duplicative — service delivery.
4. Identify and communicate major life events to relevant partners to trigger timely re-screening and service adjustments.

E. Documentation, Billing & Compliance

1. Maintain accurate, complete, and timely documentation of all billable activities in Unite Us; documentation drives reimbursement —incomplete records = unbillable services.
2. Obtain and document member consent in compliance with HIPAA and SCN consent requirements prior to Eligibility Assessment and service referral.
3. Submit required information to support Healthy Alliance’s performance reporting, including Quarterly Performance Reports and Operational Indicator Surveys.
4. Adhere to all NYS OHIP SCN Operations Manual requirements (currently Version 7, January 2026) and Healthy Alliance network policies.
5. Participate in all required training: Unite Us platform training, OHIP/Healthy Alliance SCN training, and TruCare onboarding requirements.
6. Maintain CHRC background check clearance and comply with all NYS HCS requirements.