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Healthcare Navigator

ORGANIZATION: SHELTER, Inc. is an independent, community-based non-profit organization created in 1986 to lead the effort to eliminate homelessness. We now operate in Contra Costa, Alameda, Solano and Sacramento Counties.

MISSION: To prevent and end homelessness among low-income, homeless, and disadvantaged families and individuals by providing housing services, support and resources that lead to self-sufficiency.

PURPOSE of ROLE: The Healthcare Navigator 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. This position provides case management and care coordination, health education, interdisciplinary collaboration, coordination, and consultation, and administrative duties.  SSVF Healthcare Navigators work closely with the Veteran’s primary care provider and members of the Veteran’s assigned interdisciplinary treatment team.

RESPONSIBILITIES:

GENERAL DESCRIPTION OF ASSIGNED DUTIES

Conducts assessment of the Veterans in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others.

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 plans.

Work closely with the Veteran’s assigned multidisciplinary team, including medical, nursing and administrative specialists, and case management personnel.

Work within SSVF team to provide 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.

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

Assessments should highlight the Veteran’s strengths, limitations, risk factors and internal / external supports and service needs in order to optimize the Veteran’s ability to access and maintain health care services.

HEALTH CARE TEAM AND VETERAN COMMUNICATION

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.

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.

Monitor Veteran’s progress, maintains comprehensive documentation, and provides information to the treatment team members when appropriate.

Periodically review effectiveness of resources and make modifications as needed.

Review care plan goals with Veteran and conduct regular non-clinical barrier assessments, and provide resources and referrals to address barriers as needed.

Participate as needed in the development of the Veteran’s care plan; with emphasis on community services, outreach, and referrals needed for the Veteran.

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.

SPECIALIZED CASE MANAGEMENT AND CARE COORDINATION

Provide comprehensive case management and care coordination across episodes of care—acting as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes.

Serve as the subject matter expert on community resources related to the needs of the Veteran.

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 Case Manager.

Serve as a liaison to VA and community health care programs, and represent the SSVF program in contacts with other agencies and the public.

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.

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 disciplines involved in providing care to the Veteran.

Adhere to ethical principles about confidentiality, informed consent, compliance with relevant laws and agency policies (i.e. critical incident reporting, HIPAA, Duty to Warn).

Understand the different roles within the interdisciplinary team and acts within professional boundaries.

Regularly consult with other team members and appropriately assess and address the needs of the Veteran.

ADMINISTRATIVE DUTIES AND SYSTEMS IMPROVEMENT

Assist in developing policies and procedures related to this specialty and the program.

Develop evaluation components and outcomes indicators and report those evaluation results to VA and organizational leadership

Provide subject matter expert consultation to staff and community providers on the specialty area of practice.

Enter relevant data into HMIS and other digital platforms in a timely manner.

Maintain accurate and detailed case notes.

EXPECTED PROFICIENCIES:

Knowledge of social service resource systems and self-help intervention strategies.

Independently counsel populations of mental health, substance abuse, homeless individuals

Knowledge and skills in handling substance abuse and mental health issues.  

Knowledge of public benefits and financial resources available in the community.

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 and tact/diplomacy.

Knowledge of family budgeting and money management.

Clear/firm-yet-flexible boundaries, consistent energy level and positive demeanor.

Thoroughness and accuracy with data collection, entry and quality control in a web based database. 

Professionalism: high level of integrity and strong ethical values show capacity to maintain highest standards of confidentiality with all records, including organizational and individual information.

Strong oral/written communication and listening skills.

Self-motivated and accountable for work time and other agency resources.

Quality control: demonstrates accuracy and thoroughness, monitors own work to ensure quality and applies feedback to improve performance.

Well organized: able to effectively manage multiple assignments to meet project deadlines.

Familiar with health care systems, specifically within the Veteran’s Health Administration / VA.

MINIMUM QUALIFICATIONS:

Master Degree in Social Work

2-3 years’ experience in the field of health care.

Experience working with low income and/or homeless populations.

Proficient computer skills, including Microsoft Office Suite (Outlook, Word and Excel)

Proficient typing skills.

Ability and willingness to work flexible hours to accommodate participants available during the evening or on weekends.

Experience working in diverse settings with people across all socio-economic spectrums and a wide variety of personalities and roles - staff, residents, local agencies, contractors, lenders, etc.

Access to reliable personal transportation required, including a DMV record that permits driver to be insured under SHELTER, Inc.’s automobile coverage.

Must successfully pass a criminal background check.

PREFERRED QUALIFICATIONS:

Licensed Clinical Social Worker.

Experience working with people in low-income subsidized housing arrangements and/or supportive housing programs.

Bi-Lingual English Spanish.

PHYSICAL DEMANDS:

The physical demands described below are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk and hear. The employee is often required to sit and use their hands and fingers to handle or feel objects. The employee is occasionally required to stand, walk, reach with hands and arms, climb or balance, and stoop, kneel, crouch or crawl. Specific vision abilities required by this job include close vision.

The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds.

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