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Description

Job Title: Social Care Network (SCN) Community Health Worker

Reports to: SCN Screening and Navigation Hub Manager

Project Summary: The New York State Department of Health has established Social Care Networks (SCNs) as part of the 1115 Waiver Demonstration Amendment, and Forward Leading IPA (FLIPA) is the SCN Lead for the Finger Lakes Region. This region is comprised of 14 counties, including Allegany, Cayuga, Chemung, Genesee, Livingston, Monroe, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, and Yates. 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 value individuals’ unique backgrounds, experiences, and perspectives. We are committed to fostering an environment 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.

We believe that building a strong team starts with hiring individuals whose skills and perspectives reflect the communities we serve. We actively promote opportunity for all and strive to ensure that each team member’s talents and potential are recognized and valued. Our hiring decisions are based solely on individual merit.

FLIPA is committed to prioritizing the human element in healthcare. By encouraging different viewpoints and fostering innovative thinking, we aim to build empowered, healthy, and thriving communities. Join us in making a meaningful impact.

Security Level: Standard - WLC

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.
• Associate's degree in human services, Social Work or other related degree preferred.
• 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.
• Holds self and others responsible and accountable to meet commitments.

Salary Range:

• Salary is commensurate to education and experience with a range of $38,000-$60,000

Additional information:

• This position will be primarily remote. However, given the nature of the role, approximately 50% of the workday is anticipated to include regular travel and in-community work within the Finger Lakes region for community convenings and relationship building. Occasional travel across New York State is also expected for on-site meetings or training. 
• Residency within the Finger Lakes region of New York State is required.  
  

To apply please send resume and cover letter to: jobs@forwardleadingipa.org

Description

Job Title: Social Care Network (SCN) Training Lead

Reports to: VP, SCN Strategy

Project Summary: The New York State Department of Health has established Social Care Networks (SCNs) as part of the 1115 Waiver Demonstration Amendment, and Forward Leading IPA (FLIPA) is the SCN Lead for the Finger Lakes Region. This region is comprised of 14 counties, including Allegany, Cayuga, Chemung, Genesee, Livingston, Monroe, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, and Yates. 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 oversees the design, delivery, and continuous improvement of training programs that support the NY 1115 Social Care Network’s mission to address health-related social needs (HRSN) for Medicaid members. The role involves close collaboration with community-based organizations (CBOs), managed care organizations (MCOs), and healthcare providers to ensure staff are equipped with the knowledge and skills necessary for high-quality, equitable service delivery. 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 value individuals’ unique backgrounds, experiences, and perspectives. We are committed to fostering an environment 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.

We believe that building a strong team starts with hiring individuals whose skills and perspectives reflect the communities we serve. We actively promote opportunity for all and strive to ensure that each team member’s talents and potential are recognized and valued. Our hiring decisions are based solely on individual merit.

FLIPA is committed to prioritizing the human element in healthcare. By encouraging different viewpoints and fostering innovative thinking, we aim to build empowered, healthy, and thriving communities. Join us in making a meaningful impact.

Security Level: Standard - WLC

Duties/Responsibilities:

• Develop and implement comprehensive training curricula aligned with state guidelines and SCN objectives.
• Manage relationships with external system training resources including providing direction on required training content, review and approval of training materials and input on training delivery needs.
• Ensure SCN and CBO staff are trained on workflows, documentation, HRSN screening tools, navigation protocols, and referral systems.
• Ensure completion of required training within identified timelines related to system onboarding including training compliance for new system users.
• Coordinate onboarding and ongoing professional development for frontline and administrative staff.
• Work with SCN Performance Coordinator to evaluate training effectiveness and adapt content based on performance outcomes and feedback.
• Maintain up-to-date resources, toolkits, and training guides accessible across the network.
• Support the development of a Learning Management System to house, deliver and track required training resources.
• Coordinate in-person training events as required.
• Ensure training aligns with compliance requirements, cultural competency standards, and trauma-informed care practices.
• Serve as liaison between SCN leadership, providers, and community stakeholders to assess training needs.
• Track and report on training metrics to inform continuous improvement and state reporting.

Education & Experience:

• Bachelor’s degree required in Public Health, Social Work, Health Administration, Education, or related field.
• Master’s degree (MPH, MSW, MEd, MHA, etc.) strongly preferred.
• 5+ years of experience in training, adult education, workforce development, or capacity building—ideally within healthcare, behavioral health, or community-based services.
• Experience within the New York State health care system (population health, behavioral health, Federally Qualified Health Centers, or similar) required

Skills, Knowledge, and Abilities:

• Strong understanding of social determinants of health (SDOH), Medicaid managed care, and value-based payment (VBP) models.
• Experience designing and delivering both in-person and virtual trainings.
• Excellent facilitation, presentation, and communication skills.
• Strong project management and organizational abilities.
• Familiarity with Learning Management Systems (LMS), training analytics, and reporting tools.
• Commitment to equity, inclusion, and trauma-informed practices.
• Bilingual or multilingual skills a plus.
• Flexible, adaptable style that takes in stride last minute changes and project pivots
• Ability to translate business requirements into project specifications
• Strong interpersonal skills, independently resourceful and thrives in a fully remote environment
• Proven ability to complete projects according to defined timelines and objectives

Salary Range:

• Salary is commensurate to education and experience with a range of $70,000-$90,000

Additional information:

• This position will be remote with periodic travel required for in-person meetings and training events.
• Residency within the Finger Lakes region of New York State is required.

To apply please send resume and cover letter to: jobs@forwardleadingipa.org

Description

Job Title: Care Coordination Facilitator