TRC - Fox Veterans Case Manager & Suicide Prevention Specialist (Care Coordinator)

The Resource Center•Jamestown, NY

About The Position

The Care Coordinator proactively contacts at-risk Veterans, connects them to counseling, and ensures follow-up care. This core service-delivery position coordinates services for an assigned caseload of Veterans who meet the definition of the assigned program, regulatory body, or funding entity. The Care Coordinator advocates for and supports clients, engaging with community agencies, health care providers, VA services, and others on their behalf to help ensure access to needed services. The role includes intake and eligibility verification, needs assessment, suicide-risk screening, individualized service planning, safety planning, crisis intervention, referrals, outreach, and follow-up. The Care Coordinator links Veterans to community resources and coordinates collaborative, goal-directed care, including care transitions. The position also requires accurate documentation, communication with clients and collateral contacts, participation in team meetings, and provision of self-help educational groups. The role may require non-traditional hours to meet client needs and travel for work.

Requirements

Bachelor’s degree in Social Work, Human Services, Nursing, or a related field.
One year of experience in care coordination, case management, or a related field.
Strong organizational skills to meet clients’ multifaceted needs in a timely manner.
Understanding of applicable state and federal regulations related to health homes and current working knowledge of social work best practices.
Strong analytical skills to assess baseline progress and establish or revise goals and outcomes.
Experience with individuals with disabilities and knowledge of rehabilitation and counseling services.
Comprehensive understanding of the guiding principles of rehabilitation and counseling.
Self-directed ability to initiate and manage multiple responsibilities effectively and efficiently.
Excellent verbal and written communication skills across various channels.
Flexibility and willingness to work non-traditional hours as needed or assigned to meet client needs.
Physical condition commensurate with the demands of the job.
Valid driver’s license, use of a personal vehicle, and willingness to travel for work.

Nice To Haves

Experience with Veterans services, mental health, substance abuse, or medical frailties is strongly preferred.
Proficient bilingual abilities in English and Spanish are desirable.

Responsibilities

Conduct intake, eligibility verification, and needs assessments.
Administer suicide-risk screening tools, such as the C-SSRS.
Create and monitor Individualized Service Plans (ISPs).
Provide safety planning, crisis intervention, referrals, and follow-up.
Maintain documentation of all Veteran interactions and keep records, statistics, and related reports organized, timely, and accurate according to policy and procedure.
Communicate effectively with clients, primary care physicians, substance abuse and mental health providers, families, and collateral resources.
Coordinate care planning with other service and resource providers, including care transitions, to support collaborative, goal-directed care.
Attend and participate in relevant team meetings, providing input about psychosocial and medical conditions or co-morbidities, client status, plans, goals, and outcomes.
Provide telephonic and face-to-face outreach, engagement, and service planning in the field.
Link clients to needed medical, behavioral, residential, entitlement, and other community services in accordance with the interdisciplinary care plan.
Monitor service delivery for coordination and continuity, and advocate with providers and resources as needed.
Provide self-help educational groups to clients.
Manage confidential and time-sensitive information using electronic management systems.
Communicate professionally and promptly with families, clients, staff, and outside agencies by phone and email.
Use designated electronic systems to manage work and comply with regulatory guidelines.
Seek, review, and recommend relevant updates and changes through appropriate channels.
Perform other duties as assigned.
Travel for work using a personal vehicle.