Integrated Care Coordinator - Social Care Navigator

Overview

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.

Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.

We’re looking for talented, motivated individuals to join our growing team. Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you. Join us in making a real difference in the health of our community.

Job Summary

Position Title: Integrated Care Coordinator (Social Care Navigator)

Position summary: The ICC Social Care Navigator I (SCN) is responsible for supporting front office operations, care coordination activities, and health-related social needs navigation to ensure efficient patient access, continuity of care, and overall patient support services.  

The coordinator serves as a liaison between patients, providers, community organizations, and internal departments by assisting with scheduling, patient communication, surveys, referrals, documentation, and coordination of social and nutritional services.  

In addition, the ICC Administrative Coordinator / SCN focuses on nutritional health initiatives by identifying nutritional needs, providing education, coordinating access to healthy food resources, and supporting wellness-related programs and outreach efforts. 

Responsibilities

• Perform front desk and administrative support functions including patient registration, scheduling, appointment confirmations, check-in/check-out, and insurance verification. 

• Assist with collection and documentation of copays, forms, consents, and patient demographic updates. 

• Monitor and follow up on outstanding tasks, referrals, authorizations, and patient communication requests. 

• Assist with outreach initiatives, appointment reminders, patient engagement efforts, and community-based activities. 

• Conduct outreach and engage Medicaid members telephonically and in person to assess health-related social needs. 

• Perform SCN screenings and provide comprehensive navigation for referrals to social care services. 

• Connect individuals with appropriate community resources including healthcare providers, social service agencies, food assistance programs, housing resources, transportation services, and other support organizations. 

• Facilitate referrals to services, monitor referral status, and ensure patient needs are addressed effectively. 

• Document client eligibility, outreach activities, case notes, referral outcomes, and related activities using designated technology platforms. 

• Collaborate with team members, partner-based navigators, CHWs, providers, and community organizations to support patients with complex needs. 

• Maintain accurate and compliant records of interactions, screenings, referrals, and outcomes according to organizational and regulatory standards. 
• Support care coordination efforts by assisting patients in overcoming barriers to healthcare access and treatment compliance. 
• Perform additional duties assigned by leadership and the Senior Director of NYREACH. 

Nutrition Education & Patient Support 

• Manage a caseload of assigned clients and conduct outreach, provide enhanced services, and conduct workshops, seminars, one-one consultations and presentations on healthy eating habits, disease prevention, and nutrition topics.  

• Provide personalized nutrition education and counseling to individuals and groups, focusing on healthy eating habits, meal planning, and addressing specific dietary concerns.  

• Offer clear and accurate information about healthy eating, portion control, food preparation, and the impact of nutrition on overall health.  

Qualifications

Qualifications 

• College degree required

• Experience in healthcare administration, patient navigation, social services, care coordination, or front office operations preferred. 

• Knowledge of healthcare workflows, Medicaid populations, community resources, and social care programs preferred. 

• Strong communication, customer service, organizational, and interpersonal skills. 

• Ability to multitask in a fast-paced healthcare environment while maintaining professionalism and confidentiality. 

• Proficiency with EMR systems, Microsoft Office, and data entry/documentation platforms. 

• Bilingual skills preferred. 

• Ability to work collaboratively with multidisciplinary teams and community partners. 

Required Skills:  

• Strong organizational and multitasking abilities 

• Excellent communication and interpersonal skills 

• Familiarity with medical terminology and basic understanding of healthcare procedures 

• Proficiency in using office software and electronic health record (EHR) systems. 

• Strategic and creative thinking 

• Solution-oriented mindset 

• Comfortable working in group settings 

Physical Requirements:  

• Hearing: Adequate to perform job duties in person and over the telephone. 

• Speaking: Must be able to communicate clearly in person and over the telephone. 

• Vision: Visual acuity adequate to perform job duties, including reading information from printed sources and computer screens. 

• Requires frequent bending, reaching, standing, walking, squatting, and sitting, pushing, and pulling exerted regularly throughout a regular work shift. 

• Prolonged periods of sitting at a desk and working on a computer. 

Key Competencies:  

• Customer / Patient Service  

Acknowledges patients/customers promptly in a warm, courteous manner; proactively offers to help and responds to requests for help; receives and answers patients/customers in a calm, reassuring manner; focuses attention on patients vs. personal business; answers phones, returns calls, and responds to in-person questions promptly; provides accurate information while demonstrating empathy; takes appropriate actions to ensure focus is quality patient care; treats patients, co-workers, physicians, practitioners, and colleagues as “customers”, courteous at all times; adheres to all WMG customer service standards.  

• HIPAA (Health Insurance Portability and Accountability), Confidentiality, and Infection Control Compliance   

Follows office procedures with regard to HIPAA documents and adheres to HIPAA privacy mandates; adheres to confidentiality policy; demonstrates infection control compliance relevant to job responsibilities: e.g., standard precautions.  

• Problem Solving and Judgment  

Demonstrates ability to determine best course of action for resolving issues based on presenting situation; able to assess and view situations from variety of perspectives; can dig deep to identify the real issues; solves problems and/or seeks appropriate guidance to solve problems; able to work independently and make appropriate decisions in absence of “supervisor.”  

• Communication  

Communicates effectively and clearly both verbally and in writing; conveys information and responds to all in a credible, professional, and clear manner; speaks respectfully to all; keeps others informed of relevant issues; shares information; Uses active listening skills; uses facial expressions, body language and tones of voice that convey positive messages; maintains calm in conflict situations, handling situations and people with tact and professionalism; writes accurate, understandable messages.  

• Dependability  

Reliable when it comes to attendance and punctuality; if going to be late or absent, calls supervisor in advance; respects how others on team will be impacted by lateness or absenteeism or schedule changes; present and accessible during scheduled hours.  

• Teamwork  

Pitches in when help is needed and help other team members; builds and maintains constructive relationships; engages in behaviors that support working together as a team; able to see things from another’s perspective; demonstrates work flexibility for good of WMG/team regarding locations, functions, and hours; demonstrates an awareness and sensitivity to cultural diversity.  

• Professional Appearance  

Takes pride in professional demeanor and appearance; wears appropriate attire/uniform and name tags; takes pride in appearance and cleanliness of work area; keeps work area organized with necessary clinical and non-clinical materials.  

• Willingness to Learn/Continuous Learning  

Demonstrates ability to learn new things in stated timeframe; demonstrates willingness and ability to adapt to new processes, policies, and technology changes; keeps up to date with all required education, certification, licenses; assesses and identifies own learning needs.  

• Patient/Other Contacts  

Regular patient contacts. Regular contact with families of patients, employees, and the public. 

• Working Conditions  

Intermittent exposure to one or more mildly unpleasant physical conditions.  

• Environmental Hazards  

Intermittent exposure to situations that could cause moderate to serious illness or injury.  

Equal Opportunity Employer

Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.

Compensation: 20 to 25 (USD)