Community Integration Manager Jobs in Rochester, NY

Job Title: Accountable Health PartnersCommunity Health Worker

Reports To: FLIPA Community Health Worker Supervisor and AHP

Social Care Network Summary: TheNew York State Department of Healthhas establishedSocial Care Networks (SCNs)as part of the1115 Waiver Demonstration Amendment, The SCNs aim is to enhance the delivery of social care services toMedicaid membersby coordinating efforts amongcommunity-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 systematicallyidentifies, assesses, refers, andmonitorshigh-need individuals to ensure access to essential services. By building andmaintainingkey service connections, the CommunityHealthWorkerutilizesa screening tool toidentifythe health and social needs of Medicaid recipients. This role is pivotal inidentifyingindividuals eligible for EnhancedHealth-Related Social Needs (HRSN)Services,facilitating
appropriate referrals andensuringnecessary 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 seekingassistance.

• Administers the Health-Related Social Needs Screening Tool toidentifyneeded areas of support.

• Short Term involvement with no ongoing caseload.

• Referral and Coordination:

• Facilitate referrals toappropriate communityresources and healthcare providers.

• Collaborate with the Care Team to ensuretimelyfollow-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 andassistthem 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 toidentifyindividuals 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 toidentifyindividuals 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 andmaintainemotional 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,Outlookand Word).
• NYS motor vehicle license, safe drivingrecordand 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 incommunity engagement throughout the Finger Lakes region to support community convenings and relationship building. Occasional travel across New York State is also required for onsite meetings, training, and other organizational activities.