This position systematically identifies, assesses, refers, and monitors high-need individuals to ensure access to essential services, utilizing a screening tool to identify health and social needs of Medicaid recipients. The role involves facilitating appropriate referrals, ensuring necessary linkages, and building key service connections for Enhanced Health-Related Social Needs (HRSN) Services.
Requirements summary
Candidates must possess a minimum of a High School Diploma or GED, with equivalent experience considered, alongside 1-3 years of human services experience. Essential requirements include excellent communication and customer service skills, adaptability, strong time management, basic computer literacy, and possession of a valid NYS motor vehicle license with personal vehicle availability for required travel.
high schoolCustomer ServiceTime ManagementCommunication SkillsAdaptabilityDrivingTeam CollaborationRelationship BuildingComputer LiteracyClient EngagementData DocumentationCommunity OutreachClient AdvocacyService LinkageReferral FacilitationScreening Tool AdministrationElectronic Systems Management
Job description
Job Title
Accountable
Health
Partners
Community
Health
Worker
Reports To: FLIPA Community Health Worker Supervisor and AHP
Social Care Network Summary
The New York State Department of Health has established Social Care Networks (SCNs) as part of the 1115 Waiver Demonstration Amendment, The SCN’s aim is to enhance the delivery of social care services to Medicaid members by coordinating efforts among community-based organizations (CBOs) and other health care partners to create a more resilient, flexible, and accessible social care system that reduces health disparities and advances health equity. The SCN will collaborate with CBOs and other health care partners, leveraging shared data and technology to coordinate social care services for Medicaid members to improve access, ensure reliable and timely referrals, streamline and track navigation and completed referrals in closed loop systems and enhance collaboration between social care service providers and other regional partners.
Job Summary
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 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.
Organizational
Overview: Forward Leading IPA (FLIPA) is a nonprofit membership association of safety net providers working in partnership to provide the highest quality integrated healthcare to historically underserved populations in Upstate New York since 2017. FLIPA is renowned for its commitment to integrating primary care, behavioral health, and social care needs. Our growing membership serves individuals across Upstate NY and includes federally qualified health centers (FQHCs), behavioral health providers, and a rural health network consisting of eight county public health departments.
Equal
Employment
Opportunity
Statement: At Forward Leading IPA (FLIPA), we deeply value diversity in background, experience, and thought. We are committed to creating an environment of belonging where all qualified applicants are encouraged to apply and will receive equal consideration for employment. We do not discriminate based on race, color, religion, age, sex, gender identity or expression, national origin, disability status, veteran status, or any other characteristic protected by federal, state, or local laws.
Security
Level:
Shared
Staff -
FLIPA
Duties/Responsibilities: Client Services and Goal Achievement Engages directly with individuals seeking assistance. Administers the Health-Related Social Needs Screening Tool to identify needed areas of support. Short Term involvement with no ongoing caseload.
Referral and
Coordination: Facilitate referrals to appropriate community resources and healthcare providers. 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. Client Advocacy and Support 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.
Data
Management and
Reporting: Accurately document screening results, referrals, and client interactions in electronic systems. Maintain detailed and organized records in compliance with organizational policies and standards. Collaboration and Team Integration 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. Community Outreach and Engagement Engage with community organizations to strengthen service networks and improve referral pathways. Represent the organization at community events and provide outreach to identify individuals in need of services. Provide information to community partners on mental health and substance use issues and resources. Build relationships with community organizations and service providers. Conduct outreach to identify individuals in need of services. Represent the organization at community events and stakeholder meetings.
Other duties as assigned
Education &
Experience: Minimum of High School Diploma or GED. Equivalent experience in lieu of education may be considered. Minimum of 1-3 years' human services experience.
Skills,
Knowledge, and
Abilities: Possess excellent verbal and written communication skills. Exceptional customer service skills with commitment to helping others. Ability to quickly adapt and be flexible in approach to job tasks and challenges and maintain emotional control under stress. Excellent time management skills with exceptional attention to detail and the ability to multi-task and manage multiple priorities with competing deadlines. Capability to work cooperatively with culturally diverse clients, staff, and community service providers. Basic computer literacy, including the ability to use email, conduct online research, and create basic documents (MS Office Suite including Excel, Outlook and Word). NYS motor vehicle license, safe driving record and availability of personal vehicle for work.
Pay Range
Compensation is based on education and experience, with an hourly rate of $26.44
Additional Information
This is a remote position embedded within Accountable Health Partners, a FLIPA member organization. Although primarily remote, the role requires approximately 50% travel and in‑community engagement throughout the Finger Lakes region to support community convenings and relationship building. Occasional travel across New York State is also required for on‑site meetings, training, and other organizational activities.
