Job Title: SSVF Healthcare Navigator

FLSA Status: Full Time - non-exempt
Reports to: Program Supervisor

Schedule: FT, varies
Supervises: N/A

Rate of Pay: $26/hour

Close Date: 2/6/2024

Benefits: Standard; Full-Time, Non-Exempt employees are eligible for but not limited to the following:

• Health, vision, dental, life as well as voluntary life and disability insurance
• Sick leave benefit - 1 day per month, 12 sick days per year (accrual and availability begins at hire)
• Vacation benefit - 10 vacation days per year, accrued at the rate of .0385 hours for each hour worked, excluding overtime (accrual begins at hire but may not be used until the completion of six months of employment)
• One floating day off for use (accrued immediately, and again annually, but may not be used until the completion of the initial three-month introductory period of employment)
• Pension Plan (after one year of continuous service)
• Voluntary Tax-Deferred Annuity Plan (403(b)plan)

Scope of Position/Essential Functions: The Supportive Services for Veterans Families Healthcare Navigator position provides services that include connecting Veterans to VA health care benefits or community health care services when Veterans are not eligible for VA care. This position provides some case management, but focuses on care coordination, health education, interdisciplinary collaboration, coordination and consultation, and administrative duties. SSVF Healthcare Navigators collaborate closely with the Veteran's primary care provider and members of the Veteran's assigned interdisciplinary care team.

General Duties (NOTE: This list is not meant to comprise an all-encompassing list of duties, responsibilities, or other tasks the Healthcare Navigator will be asked to perform, but is to provide a baseline for expectations)

• This position is the first point of contact for all applicants. The person in this position must be able to communicate effectively with applicants, clients, staff members, and outside agencies.
• Conducts assessment of the Veterans in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others.
• Function as a liaison between the SSVF grantee and the VA or community medical clinic and other healthcare providers, coordinating care for a population of Veterans with complex needs who require assistance accessing appropriate health care services or adhering to prescribed health care plans.
• Work closely with the Veteran's assigned multidisciplinary team, including medical, nursing, and administrative specialists, and case management personnel.
• Work within the SSVF team to provide access to timely, appropriate, Veteran centered care in an equitable manner.
• Work collaboratively with healthcare team and Veteran to identify and address system challenges for enhanced care coordination, as needed.

Non-Clinical Assessments

• 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.
• Assessments 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.
• Initial assessments will be completed as specified by the policy of the SSVF grantee and may be accomplished through virtual technology.

Health Care Team and Veteran Communication

• Work 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.
• Serve as a resource for education and support for Veterans and families and help identify appropriate and credible resources and support tailored to the needs and desires of the Veteran.
• Assess and evaluate social determinants of health for Veterans and their families while they are enrolled in the SSVF program, providing appropriate resources or referral information when needed.
• Participate as needed in the development of the Veteran's care and treatment plan; with emphasis on community services, outreach, and referrals needed for the Veteran.
• Review care and treatment plan goals with Veteran and conduct regular clinical access barrier assessments providing resources and referrals to address barriers as needed.
• Periodically review effectiveness of resources and make modifications as needed.
• Monitor Veteran's progress, maintains comprehensive documentation, and provides information to the treatment team members when appropriate.
• Use understandable language to communicate recommendations to support the Veteran and family members or caregivers and identify questions Veterans and their families may have about their treatments.

Specialized Case Management and Care Coordination

• Provide case management and comprehensive care coordination across episodes of care - acting as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes.
• Coordinate services with other organizations and programs to assure such services are complementary and comprehensive without being duplicative; directing activities to maximize effectiveness and a continuity of care for the Veteran.
• Serve as a liaison to VA and community health care programs and represent the SSVF program in contacts with other agencies and the public.
• Assist in coordinating services with the Veteran, which includes linking Veterans and caregivers to supportive services, which include, but are not limited to housing, financial benefits, and transportation - in collaboration with their SSVF housing Case Manager.
• Serve as the subject matter expert on community health resources related to the needs of the Veteran.

Health Education

• Assist in identifying the Veteran and family's health education needs and provide education services and materials that match the health literacy level of the Veteran.
• Provide ongoing education and support as needed to the Veteran and family members.

Interdisciplinary Collaboration, Coordination and Consultation

• Collaborate with other healthcare disciplines involved in providing care to the Veteran.
• Regularly consult with other team members to appropriately assess and address the needs of the Veteran and family members.
• Understand the unique roles and responsibilities within the interdisciplinary team and behave within established professional boundaries.
• Adhere to ethical principles about confidentiality, informed consent, compliance with relevant laws and agency policies (i.e., critical incident reporting, HIPPA, Duty to Warn, mandatory reporting, etc.).

Administrative Duties and Systems Improvement

• Assist in developing policies and procedures related to this specialty and the program.
• Maintain accurate and detailed case notes.
• Enter relevant data into HMIS and other digital platforms in a timely manner.
• Provide subject matter expert consultation to staff and community providers on the specialty area of practice.
• Develop evaluation components and outcomes indicators and report those evaluation results to VA and organizational leadership.

SKILLS & COMPETENCIES:

• Knowledge of social service resource systems and self-help intervention strategies.
• Independently provide basic, nonexpert's level counseling to populations experiencing mental health concerns, substance abuse, and homelessness
• Knowledge and skills in handling substance abuse and mental health issues.
• Ability to successfully develop relationships utilizing motivational interviewing techniques.
• Crisis intervention and conflict resolution skills including use of motivational interviewing, harm reduction approach, and trauma-informed care.
• Knowledge of family budgeting and money management
• Thoroughness and accuracy with data collection, entry, and quality control in a web-based database.
• Patience, tolerance, tact, and diplomacy
• Clear/firm yet flexible boundaries, consistent energy level and positive demeanor.
• Strong oral/written communication and listening skills.
• Self-motivated and accountable for work time and other agency resources.
• Familiar with health care systems, specifically within the Veteran's Health Administration/VA.
• Ability to present information to small groups.
• Must demonstrate good judgment and act in a professional manner.
• Ability to maintain confidentiality.
• Ability to meet deadlines.
• Ability to work with people from diverse populations.
• Ability to read and write in the English language.
• Must have problem-solving, listening, and organizational skills.
• Ability to multitask and prioritize according to deadlines.
• Must have time management skills.
• Ability to file and maintain files with accuracy.