Healthcare Navigator

VOA Mid-States•Beckley, WV

About The Position

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. The position provides 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. SSVF Healthcare Navigators work closely with the Veteran’s primary care provider and members of the Veteran’s assigned interdisciplinary treatment team.

Requirements

This position requires a 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.
The SSVF Healthcare Navigator works closely with the Veteran’s assigned multidisciplinary team, including medical, nursing, and administrative specialists, and the case management team. The position requires timely, appropriate, and equitable Veteran-centered care to be provided with the Veteran’s treatment team.
The Healthcare Navigator is the primary Case Manager for all Veterans placed in hotels by the SSVF program and works collaboratively with the treatment team andthe Veteran to identify and address systems challenges for enhanced care coordination as needed.
The Senior Healthcare Navigator is a liaison between all SSVF Healthcare Navigators and Veteran Services leadership, as well as the main trainer for new and existing staff.
Must have personal automobile, valid driver’s license, liability insurance, and be willing and able to travel between the counties we serve up to 70% of the time.
Must complete required case management training within 90 days of hire and complete all VA-required training for SSVF personnel and Healthcare Navigators.

Responsibilities

Conducts assessments of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others.
Purpose of 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 highlights the Veteran’s strengths, limitations, risk factors, internal/external supports and service needs to optimize the Veteran’s ability to access and maintain health care services.
Provides case management duties, including:
Meet and set up appointments with Veteran and treatment team through virtual means/telehealth.
Acts 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.
Performance Quality Improvement (PQI) duties as assigned by supervision and PQI Committee.
Work in partnership with other SSVF Case Managers, Intake Coordinators, and Outreach Workers.
Serve as a resource for education and support for Veterans and their families and helps identify appropriate and credible resources and support tailored to the needs and desires of the Veteran.
Participates in the development of the Veteran’s care plan with an emphasis on community services, outreach, and referrals needed for the Veteran:
The plan is developed in collaboration with the Veteran, their family, and their treatment team and is regularly reviewed by the SSVF Healthcare Navigator and Veteran to identify non-clinical barriers and to provide resources and referrals needed to support adherence.
Evaluates effectiveness of the resources and referrals provided and makes modifications to ensure provision of high-quality care and interventions.
Monitors Veteran’s progress, maintains comprehensive documentation, and provides information to treatment team members when appropriate.
Identifies concerns and/or questions about the Veteran’s treatment or medications and develops open communication with the provider or treatment team.
Collaborates with other providers in the ongoing reassessment of the Veteran’s health care needs.
Coordinates referrals to VA, community health clinics, and other programs needed to ensure access to health care and follows care plan to facilitate adherence and collaborates with community providers to maximize the use of VA and community resources.
Advocate for the Veteran, integrating cultural values into their care plan.
Assists Veteran in identifying methods to monitor progress toward meeting health goals and provides ongoing follow-up.
Provides health education services, materials, and referrals to Veteran and their family, based on individual needs.
Collaborates and regularly communicate with Veteran’s treatment team members to appropriately assess and address the needs of each Veteran.
Identifies systemic barriers and communicates with organizational leadership about these barriers to work collaboratively to find viable solutions.
Develop relationships with community partners, VA staff, and other referral networks.
Comply with all policies and procedures of the program and the Council on Accreditation.