Job Details

We are seeking a compassionate and detail-oriented HRSN Care Manager to support our dual program serving Medicaid enrollees with Health-Related Social Needs (HRSNs) under New York State’s 1115 Medicaid Waiver Demonstration, including the Traumatic Brain Injury (TBI) and Nursing Home Transition and Diversion (NHTD) programs.

In this role, you will provide ongoing, coordinated support to participants experiencing housing instability, food insecurity, transportation barriers, interpersonal violence, and other social determinants of health. The Care Manager will assess, plan, and manage services through a mix of telephonic and in-person interactions.

Key Responsibilities:

• Conduct comprehensive HRSN assessments and risk screenings.
• Develop and maintain individualized care plans that align with each enrollee's goals and needs.
• Coordinate services across community-based providers, housing and food support organizations, and healthcare entities.
• Ensure timely delivery of HRSN interventions, including housing navigation, case management, and peer support.
• Serve as the primary point of contact for assigned enrollees, ensuring warm handoffs and continuity of care.
• Facilitating the acquisition, oversight, and delivery of service; Ensuring annual service plans (Revised Service Plans/RSPs) are completed in a timely manner
• Conducting monthly visits via telephonic and/or in-person visits with each participant no less than once a quarter
• Addressing problems in service provision; and other matters as requested by participant or informal support.
• Maintain accurate and timely documentation in accordance with state and SCN requirements.
• Collaborate with multidisciplinary teams, including behavioral health and clinical care managers, to ensure holistic support.
• Ensure compliance with all program requirements, timelines, and documentation standards.
• Participate in case conferences, training, and program evaluations to continuously improve service quality.

Required Qualifications: Bachelor’s Degree in Social Work, Public Health, Human Services, or related field.

• At least 2 years of experience providing care coordination, case management, or social support services to Medicaid-eligible populations.
• Familiarity with trauma-informed care, cultural humility, and community-based service navigation.
• Strong interpersonal, organizational, and communication skills.
• Knowledge of community resources in Long Island and surrounding regions is preferred.
• Experience with electronic record systems and care management platforms.

Preferred Credentials:

• Certification as a Peer Specialist, Community Health Worker, or related credential (a plus).
• Bilingual proficiency (a plus).

Benefits:

• Medical, Vision & Dental
• Retirement plan (employer only contribution)
• Paid time off and Holidays
• Summer hours (9AM - 3PM, Monday - Thursday)
• Annual paid mental health week off
• Travel Stipend (quarterly)
• Holiday bonus
• Supportive team environment with training and development opportunities