Health Care Navigator

This position reports directly to assigned Program Coordinator at a U.S.VETS site. The Health Care Navigator is responsible for providing services that include connecting veterans to VA health care benefits and/or other community health care services. The Health Care Navigator provides coordination of care/case management, health education, interdisciplinary collaboration, consultation, and administrative duties. The position will work closely with the veteran’s primary care provider and members of the veteran’s assigned interdisciplinary treatment team.

Classification: Exempt

Responsibilities:

· Act as a liaison between the U.S.VETS programs 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 U.S.VETS program team to provide timely, appropriate, veteran centered care in an equitable manner.

· Assist veterans in accessing healthcare systems by facilitating enrollment, assisting with gathering/completing required documentation, following up to ensure enrollment, scheduling appointments, coordinating transportation, and problem solving any barriers.

· Conducts non-clinical assessments of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members and significant others 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.

· Health Care Team and Veteran Communication

o Work closely with veterans to assist them in communicating their preferences in care and personal health-related goals to facilitate informed/shared decision making for care.

o Serve as a resource for education and support for veteran families and help identify credible resources and supports tailored to the needs/desires of the veteran.

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

o Review care plan goals with veteran and resource effectiveness; conduct regular non-clinical barrier assessments; provide resources and referrals to address barriers as needed.

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

o 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.

· Specialized Care Coordination

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

o Coordinate health and wellness 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.

o 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 the veteran’s primary/housing Case Manager.

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

o Independently provides support to populations of mental health, substance abuse, homeless individuals.

o Applies knowledge of social service resource systems to include public benefits and financial resources and self-help intervention strategies to include coordinating care for substance abuse and mental health.

o Successfully develop relationships and conduct crisis intervention and conflict resolution utilizing motivational interviewing, trauma-informed care, and harm-reduction techniques.

o Practices patience, tolerance, tact, and diplomacy while maintaining a positive demeanor with clear/firm-yet-flexible boundaries in work with clients, teammates, providers, and the community.

· Health Education

o 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.

o 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.
• Regularly consult with other team members and appropriately assess and address the needs of the veteran.
• Understand the different roles within the interdisciplinary team and acts within 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).

· Administrative and Systems Improvement

• Assist in developing policies and procedures related to this specialty and the program.
• Thoroughly and accurately enter relevant data and/or case notes into HMIS, electronic case records, 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 organizational leadership and VA.

Additional Program-Specific Duties:

· The Health Care Navigator reports to the Program Coordinator for the primary program assigned to.

· Health Care Navigators assigned to the Supportive Services for Veteran Families Program (SSVF) shall gain and maintain knowledge of the SSVF program to include eligible activity, client eligibility, goals, and regulations and are also to become knowledgeable of all U.S.VETS programs and share resources and care coordination efforts.

· Other duties as assigned.

Requirements:

· Master’s degree in Social Work; Master’s degree in a closely related social service field that is equivalent and approved by agency per funder guidelines may be considered.

· License in Clinical Social Work preferred.

· 2-3 years’ experience in the field of health care and/or medical social work.

· Experience working with low income and/or homeless populations, preferably those in low-income subsidized housing arrangements and/or supportive housing programs.

· Proficient typing and computer skills, including Microsoft Office 365 (Outlook/Word/Excel)

· Ability and willingness to work flexible hours to accommodate participants which may include evenings and/or weekends.

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

· 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, well-organized, and accountable for work time, deadlines, and agency resources.

· Quality control: demonstrates accuracy and thoroughness, monitors own work to

ensure quality and applies feedback to improve performance.

· Familiar with health care systems, preferably with the Veteran’s Health Administration.

· Access to reliable personal transportation required, including a Valid driver’s license; must meet company insurance requirements and complete a provided driver training course.

United States Veterans Initiative is a non-profit organization whose mission is the successful transition of military veterans and their families through the provision of housing, counseling, career development and comprehensive support.

REV 9.3.2020

Job Type: Full-time

Pay: From $48,400.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 10 hour shift
• 8 hour shift

Education:

• Master's (Required)

License/Certification:

• Drivers License (Required)
• Hawaii Social Worker License (Preferred)

Shift availability:

• Day Shift (Preferred)
• Night Shift (Preferred)

Work Location:

• One location

Benefit Conditions:

• Waiting period may apply

Work Remotely:

• No

COVID-19 Precaution(s):

• Remote interview process
• Personal protective equipment provided or required
• Plastic shield at work stations
• Temperature screenings
• Social distancing guidelines in place
• Virtual meetings
• Sanitizing, disinfecting, or cleaning procedures in place

Work Location: One location

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