Healthcare Navigator

POSITION SUMMARY

The SSVF program assists Veterans who are homeless or at-risk of homelessness end their housing crisis. The goal of the SSVF Healthcare Navigator is to provide services that assist veterans in ending their housing crisis, enhance their independent living skills by providing supportive services and education, connect them with community resources, and empower them to maintain long-term housing stability and self-sufficiency.

RESPONSIBILITIES

• Access local resources, advocate, counsel, and work cooperatively with local service providers
• Be the liaison between VOA Mid-States and the VA or community medical clinic
• Provide services that include connecting Veterans to VA health care benefits or community health care services where Veterans are not eligible for VA care, health education, interdisciplinary collaboration, and overall case management and care coordination
• Work closely with the Veteran’s assigned multidisciplinary team, including medical, nursing, and administrative specialists, and the case management team
• Meet and set up appointments with Veteran and treatment team through virtual means/telehealth
• Act as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes
• Perform assessments, develop/monitor case plans, and conduct necessary follow-up activities
• Establish linkages with appropriate agencies and service providers in the area/community
• Provide referrals and resources
• Educate participants on issues, such as supportive services available and participant rights
• Provide supportive services to participants
• Complete required documentation (including progress notes) within 48 hours of contact and enter data into the Homeless Management Information System (HMIS)
• Demonstrate good clinical judgement in decision making regarding participants
• Demonstrate ability to relate to Veterans and their families in a culturally competent manner
• Participate in the development of the Veteran’s care plan with an emphasis on community services, outreach, and referrals needed for the Veteran
• Evaluate effectiveness of the resources and referrals provided and make modifications to ensure provision of high-quality care and interventions
• Maintain comprehensive documentation and provide information to treatment team members when appropriate
• Identify concerns and/or questions about the Veteran’s treatment or medications and develop open communication with the provider or treatment team
• Collaborate with other providers in the ongoing reassessment of the Veteran’s health care needs
• Coordinate referrals to VA, community health clinics, and other programs needed to ensure access to health care and follow care plan to facilitate adherence and collaborate with community providers to maximize the use of VA and community resources
• Advocate for the Veteran, integrating their needs/wants into their case plan
• Assist Veteran in identifying methods to monitor progress toward meeting health goals and provide ongoing follow-up
• Provide health education services, materials, and referrals to Veteran and their family, based on individual needs
• Collaborate and regularly communicate with Veteran’s treatment team members to appropriately assess and address the needs of each Veteran
• Develop relationships with community partners, VA staff, and other referral networks

QUALIFICATIONS

• Knowledge and ability to access local resources, advocacy, counseling, and working cooperatively with local service providers
• Excellent judgment and demonstrated ability to provide a reasonable combination of knowledge, abilities, and skills
• Knowledge and ability to provide services that include connecting Veterans to VA health care benefits or community health care services where Veterans are not eligible for VA care, health education, interdisciplinary collaboration, and overall case management and care coordination
• Ability to be the liaison between VOA Mid-States and the VA or community medical clinic
• Work with a population of Veterans with complex needs who require assistance accessing health care services or adhering to health care plans
• Master of Social Work or a Master’s degree in a related field and less than five (5) years of work experience in the field; a person with a Bachelor of Social Work or a related undergraduate degree with more than five (5) years related work experience; a person with nine (9) years of experience in the field and no degree; or a veteran with six (6) years of experience in the field