PositionTitle:SSVF Health Care Navigator

Supervisor:SSVF Program Coordinator

Department:Human Services

Exemption:Non- Exempt

Updated:April 2024

Job Summary:

As part of the Supportive Services for Veteran Families (SSVF) team, the Health Navigator will link Veterans experiencing or at risk for homelessness to medical care, behavioral health treatment, benefits, etc. focusing on those Veterans who may be disconnected from services and/or are struggling with active substance use, mental health disorders and/or chronic medical conditions.

This position provides care coordination, case management, health education and collateral contacts to ensure that Veterans are connected to the care, treatment and services that will lead to improved health outcomes and self-determination.

This position must be dedicated to the Harm Reduction service delivery model and will employ a variety of evidence-based interventions including Motivational Interviewing, Trauma Informed Care and Relapse Prevention to provide client centered services to Veterans.

Job Responsibilities:

• Work closely with the Veteran’s primary care provider and members of the Veteran’s assigned interdisciplinary treatment team and act as a liaison between SSVF and the VA and/or other medical providers to link and retrain Veterans in medical and behavioral health care and treatment. Connect to telehealth as appropriate.
• Conduct comprehensive assessments, in collaboration with other interdisciplinary treatment team members and family members (as appropriate), to understand the Veteran’s situation and barriers to care/treatment, and to create a Veteran centered care plan that outlines a Veteran’s goals and objectives.
• Act as a health coach by proactively supporting Veterans to optimize treatment interventions and outcomes through working to resolve concerns or questions about their treatment, medications, etc. and communicating their preferences in care and personal health-related goals to interdisciplinary treatment team members.
• Coordinate referrals to the VA, community health clinics, and other programs to ensure access to health care and other services. Follow the care plan to facilitate adherence and collaborate with community providers to maximize the use of VA and community resources.
• Link Veterans and family members to supportive services, which include, but are not limited to, housing, financial benefits, transportations, etc.
• Serve as a subject matter expert on community resources related to the needs of Veterans and provide education to Veterans and their family on the available services to assist them in establishing the appropriate, Veteran centered referrals and linkages to care.
• Provide trainings to other team members on navigating the VA and community-based services, including medical care, behavioral health care as well as other community-based resources.
• Consult regularly with other team members to appropriately assess and address the needs of the Veteran.
• Respond to crisis situations and intervene when needed and alerted. Respond and follow up with event reports.
• Ensure all data collection and documentation deadlines are adhered to.
• Provide community-based referrals to meet the needs of each Veteran during discharge planning to help maintain independent living. Provide appointment accompaniment as needed.
• Provide direct stabilization case management services as needed.
• Attend and actively participate in department, case conferencing, program meetings and trainings as required.
• Perform other duties as assigned.