Health Care Navigator - SSVF

About the Role

Provide services connecting SSVF eligible Veterans who are homeless or at risk of homelessness to VA health care benefits, or community health care when Veterans are ineligible for VA care. Offer case management, care coordination, health education, interdisciplinary collaboration, consultation, quality improvement, and risk management in partnership with the Veteran’s primary care provider and the assigned interdisciplinary treatment team.

Responsibilities

• Non-Clinical Assessment: Following intake, engage Veterans in a non-clinical assessment of their health/mental health situation, potential barriers to care, causes, and the impact of barriers on their ability to access and maintain health care services. Obtain secondary and tertiary information in collaboration with the interdisciplinary team, family members, health care providers, and significant others to develop a comprehensive understanding of the Veteran’s health care needs. Ensure appropriate releases of information are obtained and confidentiality requirements are observed.
• Health Care Team and Veteran Communication: Work closely with Veterans to communicate their care preferences and personal health goals to health care providers, facilitating shared decision-making. Serve as a resource for education and support for Veterans and families, identifying appropriate Veteran-centered supports.
• Community Services, Outreach, and Referrals: Develop the Veteran’s SSVF health care plan with an emphasis on community services, outreach, and referrals. Collaborate with the interdisciplinary treatment team, Veteran, family members, and significant others to incorporate measurable goals. Regularly review care plan goals with the Veteran, conduct ongoing non-clinical barrier assessments, and provide resources and referrals to support adherence. Evaluate the effectiveness of resources and referrals and modify as needed to ensure high-quality care.
• Specialized Case Management and Care Coordination: Provide comprehensive case management and care coordination across episodes of care, acting as a health coach to proactively support the Veteran in optimizing treatment interventions and outcomes. Modify services to meet the Veteran’s needs and coordinate with other organizations/programs to ensure complementary and comprehensive services. Represent the program in contacts with other agencies and the public. Coordinate additional supportive services, including housing, financial benefits, and transportation. Coordinate referrals to VA, community health clinics, and other programs to ensure access to health care. Advocate for the Veteran, integrating their cultural values into the care plan.
• Health Education: Educate Veterans and caregivers on available services and assist with referrals based on Veteran preferences. Identify the Veteran and family's health education needs and provide education services and materials that match their health literacy level. Offer ongoing education support as needed.
• Interdisciplinary Collaboration, Coordination, and Consultation: Collaborate with health care providers, the interdisciplinary care team, and the SSVF team to promote the highest level of quality care. Consult regularly on ongoing assessment of Veteran needs while respecting professional boundaries and roles.
• Risk Management & Infection Control: Complete required training, including Safe from Harm, Blood Borne Pathogens, The Salvation Army’s Case Work Certification Program, Confidentiality, Ethics, Suicide Prevention, and all SSVF Health Care Navigator training. Report accidents or injuries and follow risk management plans, infection control practices, and safety protocols, including COVID-19 prevention measures.
• Confidentiality, Computer Security, and Ethical Practice: Adhere to ethical standards of practice, including confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., HIPAA, Duty to Warn). Maintain client confidentiality in accordance with established procedures and regulations.
• Continuous Quality Improvement (CQI) and Systems Improvement: Participate in expanding knowledge related to health care navigation for the Veteran population. Collaborate with supervisors to review research-based best practices and suggest improvements to service delivery. Participate in case reviews, progress updates, and team meetings. Submit monthly reports on activities and unmet needs. Attend in-service and outside trainings as requested.
• Customer Service: Participate effectively in team meetings, case conferences, and related activities. Collaborate with multidisciplinary team members to enhance coordination of comprehensive Veteran care. Communicate effectively with community agencies to facilitate continuity of care.
• Age, Development, and Cultural Needs of Veteran Clients: Demonstrate sensitivity to all Veterans’ needs concerning age, developmental requirements, and culturally related factors. Consider age-related differences in the provision of care.

Requirements

• Education: Bachelor’s degree required; equivalent years of experience may substitute.
• Experience: Prior experience performing medically based case management preferred. Experience serving homeless populations and Veterans preferred, along with experience in crisis intervention and community resources.
• Skills/Abilities:
  • Advanced case management skills in a medical or medical case management environment.
  • Ability to function independently while seeking supervisory consultation.
  • Sound judgment and initiative based on education, training, and experience.
  • Competence in computer technology for documentation, data entry, and virtual technologies.
  • Ability to concentrate mental and visual attention closely on work for sustained periods.
  • Critical thinking and creative problem-solving skills.

Skills, Competencies & Key Performance Indicators

• Collaboration & Team Work: Builds good working relationships, collaborates with staff, supervisors, managers, and external partners. Works effectively as part of a team to achieve organizational goals.
• Attendance & Timeliness: Demonstrates consistent attendance and punctuality. Prioritizes tasks effectively and meets deadlines.
• Communication: Communicates professionally and respectfully with coworkers, supervisors, clients, and community partners. Demonstrates effective listening, presentation, and public speaking skills.
• Financial Impact: Values and efficiently uses organizational resources, including grant funds. Completes annual fraud prevention training and follows risk management protocols.
• Flexibility & Adaptability: Accepts change positively and adapts to evolving organizational and program needs.
• Initiative: Proactively recommends improvements and seeks solutions to program processes or barriers. Works autonomously with minimal supervision.
• Innovation & Creativity: Demonstrates openness to new ideas and methodologies. Generates solutions for continuous quality improvement.
• Self-Development: Continuously seeks opportunities to learn new skills and grow professionally. Attends relevant training, webinars, and workshops.
• Cultural Competency: Adaptable in culturally diverse environments, with respect for cultural differences and comfort working with military and veteran cultures.
• Community Practice: Engages with others, forms collaborative alliances, and influences and motivates to achieve shared goals.