Veteran Services Health Care Navigator

Position Summary:

The SSVF Health Care Navigator will act as a liaison between the SSVF Grantee and the VA or community medical clinic and works with a population of Veterans with complex needs who require assistance accessing health care services or adhering to health care plans.

The SSVF Health Care Navigator provides services that include connecting Veterans to VA health care benefits or community health care services where Veterans are not eligible for VA care. As well as provide case management and care coordination, health education, interdisciplinary collaboration, coordination, and consultation, and administrative duties.

The SSVF Health Care Navigator works closely with the Veteran’s primary care provider and members of the Veteran’s assigned interdisciplinary treatment team and Veteran’s assigned multidisciplinary team, including medical, nursing, and administrative specialists, and case management personnel to ensure timely, appropriate, Veteran centered care equitably. The SSVF Health Care Navigator works collaboratively with the team and the Veteran to identify and address systems challenges for enhanced care coordination as needed.

The SSVF Health Care Navigator reports to the Direct Client Services Team Lead who will provide supervision and guidance and provide assignments. The SSVF Health Care Navigator is expected to function independently, exercising initiative and judgment in day-to-day activities, based on expertise accumulated through education, training, experience, and reference to relevant professional literature. They will seek consultation with the supervisor as appropriate and needed.

Position Responsibilities:

· Conducts assessments of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others.

· The purpose of the assessment is to understand the Veteran’s situation, potential barriers to care, the causes, and the impact of such barriers on the Veteran’s ability to access and maintain health care services.

· The assessment should highlight the Veteran's strengths, limitations, risk factors, and internal/external supports and service needs to optimize the Veteran's ability to access and maintain health care services.

· The initial assessment will be completed as specified by the policy of the SSVF Grantee. An assessment may be accomplished through virtual technology.

· Works closely with Veterans to assist them in communicating their preferences in care and personal health-related goals to facilitate shared decision making of the Veteran’s care.

· Serves as a resource for education and support for Veterans and families and helps identify appropriate and credible resources and support tailored to the needs and desires of the Veteran.

· May participate in the development of the Veteran’s care plan; however, the health care navigator’s emphasis is on community services, outreach, and referrals needed for the Veteran. The plan is developed in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others, and incorporates measurable goals.

· Regularly reviews care plan goals with the Veteran, conducts regular non-clinical barrier assessments, and provides resources and referrals needed to support adherence.

· Periodically evaluates the effectiveness of the resources and referrals provided and makes appropriate modifications to ensure the provision of high-quality care and interventions.

· Monitors Veteran’s progress, maintains comprehensive documentation, and provides information to treatment team members when appropriate.

· Reiterates provider recommendations using clear language to support the Veteran and family members or caregivers.

· Assists Veterans in identifying concerns or questions about their treatment or medications to develop open communication with the provider or treatment team.

· Provide comprehensive case management and care coordination across episodes of care by acting as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes.

· Modify services to meet the needs of Veterans best and coordinates services with other organizations and programs to assure such services are complementary and comprehensive; directs activities to maximize effectiveness, efficiency, and continuity of care for Veterans; provides case management services to Veterans serves as the liaison to VA and community health care programs and represents the program in contacts with other agencies and the public.

· Coordinate supportive and additional services with the Veteran and ensures and links Veterans and caregivers to supportive services, which include, but are not limited to, housing, financial benefits, transportation.

· Serve as the subject matter expert on community resources related to the needs of the Veteran.

· Collaborate with other providers in the ongoing reassessment of the Veteran’s health care needs.

· Be responsible for educating the Veteran and caregivers of the available services and assisting them in establishing the appropriate referrals based on the Veteran’s preference.

· Determine the needs, strengths, limitations, and preferences of each Veteran and will engage in problem-solving to identify and reduce barriers to care.

· Educate the Veteran and family on the available options for acquiring knowledge and skills for managing health and wellness.

· Coordinates referrals to VA, community health clinics, and other programs needed to ensure access to health care.

· Follows the care plan to facilitate adherence and collaborates with community providers to maximize the use of VA and community resources.

· Acts as an advocate for the client, integrating the Veteran’s cultural values into their care plan.

· Assists the Veteran in identifying methods to monitor progress toward meeting health goals and provides ongoing follow up.

· Assists in identifying the Veteran and family's health education needs and provides education services and materials that match the health literacy level of the Veteran.

· Provides ongoing education support as needed to the Veteran and family members.

· Assists in identifying VA and community resources to prevent disease and promote self-care. For specialized health education outside of the incumbent’s scope of practice, the health care navigator will refer Veterans and families to the appropriate interdisciplinary team member for identified health education needs.

· To ensure the best possible care, collaborates with other disciplines involved in providing care.

· Regularly consults with other team members and appropriately assesses and addresses the needs of the Veteran.

· Understands the different roles within the interdisciplinary team and acts within professional boundaries.

· Adheres to ethical principles about confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., critical incident reporting, HIPPA, Duty to Warn).

· Participates in expanding the knowledge related to health care navigators and the Veteran population.

· Identifies systemic barriers within the organization, communicates with organizational leadership about these barriers, and works collaboratively to find viable solutions.

· Assists in developing policy, procedures, and practice guidelines related to the specialty program using knowledge gained from research or best practices.

· Develop relationships with community leaders, VA staff, and other referral networks.

· Provides subject matter expert consultation to staff and community providers on the specialty area of practice.

· May develop evaluation components and outcomes indicators and report those evaluation results to VA and organizational leadership.

· Effectively in team meetings, case conferences, and related activities. Collaborates with multidisciplinary team members in a manner that enhances the coordination of comprehensive Veteran care.

· Effectively communicates with and utilizes community agencies to facilitate continuity of care. With few exceptions, gives evidence of having regular contact and interaction with a variety of community agencies and resources. Collaborates with a variety of community agencies and engages in problem resolution activities.

· The employee’s relationship with supervisors, co-workers, patients, visitors, and the general public is consistently courteous and cooperative and contributes to the effective operation of the case management program. Any failure in this area is limited, minor, and has no significant adverse impact on the Service. He/she anticipates and avoids potential causes of conflict, and activity promotes cooperation among co-workers.

· The primary age of Veteran participants cared for are generally at the middle-aged adult level, i.e., 40 years of age or older. However, occasionally there may be younger Veterans between the ages of 18-40 years of age that require care. Sensitivity to all Veterans' individual needs concerning age, developmental requirements, and culturally related factors must be consistently achieved.

· Takes into consideration age-related differences of the various Veteran populations served:

· a) Young adulthood (20-40). Persons, in general, have normal physical functions and lifestyles. Establishes relationships with significant others and is competent to relate to others.

· b) Middle aged (40-65). Persons may have physical problems and may have lifestyle changes because children have left home or transition in occupation goals.

· c) Older adulthood (65-75). Persons may be adapting to retirement and changing physical abilities. Chronic illness may also develop.

· d) Middle-old (75-85). Persons may be adapting to a decline in the speed of movement, reaction time, and sensory abilities. Also, persons may have increased dependence on others.

· e) Old (85 and over). Increasing physical problems may develop.

· Protects printed and electronic files containing sensitive data following the provisions of the Privacy Act of 1974 and other applicable laws and organization policy.

· Protects the data from unauthorized release or loss, alteration, or unauthorized deletion.

· Follows applicable regulations and instructions regarding access to electronic files, the release of access codes, and the use of electronic information.

· Uses word processing software to execute several office automations functions such as storing and retrieving electronic documents and files; activating printers, inserting and deleting text, formatting letters, reports, and memoranda; and transmitting and receiving e-mail.

· Appropriately uses equipment and supplies; maintains a safe and orderly work area; reports any accidents to self or patients and completes appropriate documentation.

· Follows Life Safety Management (fire protection) procedures; reports safety hazards, accidents, and injuries; reviews hazardous materials/Material Safety Data Sheets (MSDS)/waste management.

· Follows Emergency Preparedness plan; follows security policies/procedures; complies with federal, state, and local environmental and other requirements preventing pollution, minimizing waste, and conserving cultural and natural resources; and demonstrates infection control practices for disease prevention (i.e., hand washing, universal precautions/isolation procedures, including TB requirement/precautions).

· Other duties, as assigned

Position Requirements:

· Educational background can be diverse; however, a degree in a related field or a minimum of three (3) years of relevant work experience preferred

· Experience working or volunteering in nonprofit or government settings addressing housing or other social services preferred

· Lived experience with homelessness preferred

· Veterans and/or experience working with Veterans preferred

Knowledge, Skills, and Abilities Required:

· Excellent judgment

· Knowledge of various homeless interventions and Housing First practices

· Ability to work alone on own initiative, often with minimum supervision, as well as part of a small team

· Working knowledge of community Veteran resources

· Skilled at building trust and rapport with people from diverse backgrounds

· Skilled in the use of personal computers, including knowledge of Microsoft Office, and ability to learn and correctly enter data into the Homeless Management Information System

· Ability to remain calm in stressful/chaotic situations

Physical Demands:

· Periods of walking, standing, or sitting in an office or field environment for service provision

· Limited physical effort required; however, the employee must occasionally lift and/or move up to 15 pounds

· Ability to operate a motor vehicle

Employment Disclaimer

Employment with Changing Homelessness, Inc. is contingent upon meeting applicable eligibility and compliance requirements following a conditional offer of employment. These may include authorization to work in the United States, required background and drug screenings, and maintaining a valid driver’s license. Client-facing roles require access to a reliable vehicle.

Candidates who are current clients or who have received services within the past 90 days are not eligible for consideration. Former employees eligible for rehire must wait 90 days from their separation date before reapplying.

Changing Homelessness, Inc. does not discriminate on the basis of any status protected by applicable law.

Pay: $46,000.00 - $51,000.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Paid sick time
• Paid time off
• Tuition reimbursement
• Vision insurance

Work Location: In person

Salary : $46,000 - $51,000