1. SCOPE OF ROLE:

S:US provides high-quality, person-centered Rapid Re-Housing and Homeless Prevention services to low-income veteran households who are unhoused or experiencing housing instability. The Healthcare Navigator position provides services that include connecting Veteran households to VA health care benefits and to community health care services, working closely with the full SSVF team to maximize participants access to clinical support and healthcare services.  This position provides case management and care coordination, health education, benefits/insurance referrals, and follow up administrative duties to support the needs of enrolled participants in the SSVF program. SSVF Healthcare Navigators work closely with the Veteran’s primary care provider and community-based healthcare services, and coordinate service delivery for the household with members of the Veteran’s assigned SSVF housing and case management team.

1. ESSENTIAL DUTIES & RESPONSIBILITIES:

• Conducts assessments of Veteran households in collaboration with the full SSVF team and, when appropriate, the participants’ community/VA healthcare providers.
• Complies with all HIPAA rules when navigating veterans to healthcare resources that meet their needs, preferences and desired outcomes.
• Maintain a caseload of SSVF participants, supporting their access to permanent housing, income and benefits maximization and other core services.
• Maximize Veterans’ ability to access and maintain health care services.
• Act 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 health care services or adhering to health care Support participants’ access to healthcare resources and services whenever feasible.
• Work closely with the Veteran’s assigned multidisciplinary team, including medical, nursing and administrative specialists, and case management
• Work within SSVF team to provide timely, appropriate, person-centered care.
• Work collaboratively with healthcare team and Veteran family to identify and address system challenges for enhanced care coordination as needed.
• Work closely with Veterans to assist them in communicating their preferences in care and personal health-related goals, in order 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 supports tailored to the needs and desires of the Veteran.
• Participate as needed in the development of the Veteran’s care plan; with emphasis on community services, outreach, and referrals needed for the Veteran.
• Review care plan goals with Veteran and conduct regular non-clinical barrier assessments and provide 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 clear language to communicate recommendations to support the Veteran and family members or care givers, as well as identify questions Veterans and their families may have about their treatments.
• 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.
• Coordinate services with other organizations and programs to assure such services are complementary and comprehensive, 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 supportive and additional 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 resources related to the needs of the Veteran.
• 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.
• Collaborate with other disciplines involved in providing care to the
• Regularly consult with other team members and appropriately assess and address the needs of the
• Adhere to ethical principles about confidentiality, informed consent, compliance with relevant laws and agency policies (i.e. critical incident reporting, HIPPA, Duty to Warn).
• Maintain accurate and detailed case
• Enter relevant data into HMIS and other digital platforms in a timely
• Prioritizes and manages multiple projects simultaneously and following through on issues in a timely manner.
• Responds to participant and stakeholder needs promptly, accurately and with courtesy and respect.
• Models appropriate behavior and represent the organization in a positive and appropriate manner.
• 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.
• Respond to client needs promptly, accurately and with courtesy and respect. Deliver high-quality customer services to all stakeholders.
• Partners with programs to improve the efficiency and quality of the delivery of services.
• Assists with accreditation reviews, monitoring visits and program audits.
• Promotes the SSVF Housing First model of service delivery, especially for people who present with highest barriers to accessing and maintaining permanent housing.
• Available for after-hours crisis response as needed.
• Conducts fieldwork up to 50% of the work week; available for in-office work daily/as needed.
• Adapts and improved service models to be responsive to a changing environment and individualized needs/goals of the veteran families we serve.
• Participate in program/division management meetings as needed and facilitates staff meetings, case conferences, COC/partners meetings as appropriate.
• Remains current and updated on new regulations, policies, industry trends, and best practices.
• Represents the agency and programs and in a professional manner to funders, consumers, potential consumers, referring agencies, network members, etc.
• Perform other duties as required

REQUIRED EDUCATION AND EXPERIENCE

• Bachelor’s Degree Required, Master’s preferred.
• Minimum of 4 years of professional experience.
• Demonstrated proficiency with Microsoft Windows, Microsoft Word/Excel/Outlook required.

·         Effective written and oral communication skills.

PREFERRED QUALIFICATIONS & SKILLS

• Understanding of health care system and/or Veterans Health Administration (VHA).
• Experience working with low income, homeless populations and/or Veterans
• Solid organizational skills/strong communication and writing skills
• Willingness to attend occasional events outside of normal business hours, including Veterans Day.
• High energy level to complete assigned work and meet deadlines.
• Veterans strongly encouraged to apply.

S:US IS AN EQUAL OPPORTUNITY EMPLOYER

Join a team of employees who cares about the wellbeing of others.  We believe in fostering a culture built on our core values:  respect, integrity, support, maximizing individual potential and continuous quality improvement. 

S:US is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. S:US is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities, including allowance of the use of services animals. To request reasonable accommodation or if you believe such a request was improperly handled or denied, contact the Director of Benefits & Compensation at MyMedicalLeave@sus.org.