Veteran Case Manager

The Transition House Inc.•Kissimmee, FL

9d•Hybrid

About The Position

The Transition House, Inc. is seeking a compassionate, resourceful Veteran Case Manager to provide community-based, non-clinical suicide-prevention case management through our Veteran Connection and Suicide Prevention Program. In this role, you will help Veterans reduce barriers, strengthen protective factors, navigate VA and community systems, and stay connected to individualized services and supports. Participants may be experiencing housing instability, unemployment, financial hardship, behavioral-health or substance-use concerns, social isolation, family stress, justice involvement, transportation barriers, or disconnection from VA services. Veterans and candidates with direct experience serving Veterans and Veteran families are strongly encouraged to apply. If you are skilled at building trust, coordinating across systems, documenting carefully, and staying steady when someone needs immediate support, we would like to meet you.

Requirements

Bachelor's degree in social work, human services, psychology, counseling, criminal justice, or a related field, or equivalent relevant experience serving Veterans or other vulnerable populations.
Experience providing case management, care coordination, outreach, resource navigation, or social services.
Strong interpersonal, engagement, documentation, organizational, and follow-through skills.
Ability to work independently in community settings while managing an assigned participant caseload.
Ability to coordinate across VA, housing, benefits, behavioral-health, legal, employment, and other service systems.
Ability and willingness to complete required training and demonstrate competency in VA-required suicide-prevention screening and related program tools.
Sound judgment and the ability to follow established participant-safety, crisis-escalation, warm-handoff, consent, and confidentiality procedures.
Valid driver's license and ability to travel regularly throughout Orange and Osceola Counties and the surrounding service area.
The selected candidate must complete required training and demonstrate competency in: TTHI onboarding and SSG Fox SPGP requirements, including confidentiality, documentation, participant safety, trauma-informed care, Veteran-specific service delivery, VA coordination, warm handoffs, crisis escalation, and family or support-system engagement.
Administering, scoring, documenting, and responding to VA-required suicide-risk screening, baseline mental-health or wellbeing screening, and other assigned SSG Fox tools.
Immediate escalation, referral, warm-handoff, and emergency-response procedures whenever elevated or imminent suicide risk is identified. Standardized screening does not replace clinical evaluation.

Nice To Haves

Veterans and candidates with experience supporting Veterans and families.
Experience with VA programs, GPD, SSVF, HUD-VASH, homelessness, reentry, housing, or behavioral health, along with knowledge of Central Florida resources and trauma-informed care, is strongly valued.
Veteran status is not required.

Responsibilities

Conduct community outreach and engage Veterans referred through VA, TTHI programs, hospitals, shelters, housing providers, corrections and reentry systems, county partners, and other community sources.
Complete SSG Fox eligibility screening and, after required training and competency validation, administer VA-required suicide-risk, baseline mental-health or wellbeing, and other assigned screening or outcome tools.
Develop and update individualized suicide-prevention service plans while managing an assigned caseload at a frequency based on participant risk, need, and goals.
Help Veterans access VA healthcare, VA homeless services, benefits, housing, employment, public benefits, transportation, legal and reentry resources, behavioral-health referrals, identification documents, and other stabilization supports.
Coordinate warm handoffs through direct provider contact, appointment coordination, transportation assistance when appropriate, and follow-up to confirm a successful connection.
Work closely with Veteran Peer Support Specialists and the Veteran Community Outreach and Reentry Specialist to strengthen engagement, retention, and service connection.
Identify suicide risk, immediate safety concerns, behavioral-health concerns, and psychosocial risk factors through required screening and ongoing participant engagement.
Immediately escalate elevated or imminent suicide risk and coordinate same-day warm handoffs to VA Suicide Prevention Coordinators, the Veterans Crisis Line or 988, mobile crisis, emergency services, or other appropriate resources.
Provide increased outreach after a recent crisis, incarceration, homelessness, difficulty remaining engaged, or lack of VA connection, and complete assigned reassessments and post-service screening with accurate follow-up documentation.
With participant consent, involve family members, caregivers, and other Veteran-identified natural supports in service planning, resource coordination, and follow-up when their involvement supports the Veteran's goals and safety.
Provide education on suicide warning signs, Veterans Crisis Line and 988 resources, help-seeking, safety planning, and approved lethal-means safety information.
Identify family or caregiver needs that may affect the Veteran's stability or engagement and connect them with appropriate community resources.
Document participant consent, family and natural-support engagement, education, referrals, releases, and follow-up in accordance with confidentiality requirements.
Complete timely service notes, referrals, releases, service plans, screening records, and required grant data in secure documentation systems.
Participate in supervision, case reviews, quality reviews, multidisciplinary meetings, partner coordination, and required VA or grant training.