Health Care Navigator - Supportive Services for Veteran Families (SSVF)

Job Objective: Provide services connecting SSVF eligible Veterans who are homeless or at risk of homelessness to VA health care benefits, or community health care when Veterans are ineligible for VA care. Provide case management, care coordination, health education, interdisciplinary collaboration, consultation, quality improvement, and risk management working with the Veteran's primary care provider and the assigned interdisciplinary treatment team.

Essential Functions:

This job description should not be interpreted as all inclusive. It is intended to identify the essential functions and requirements of the position. Other job related responsibilities and tasks may be assigned. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job functions.

• Non-Clinical Assessment: Following intake, engage Veterans in a non-clinical assessment of the Veteran's health/mental health situation, potential barriers to care, causes, and the impact of barriers on the Veteran's ability to access and maintain health care services. Obtain secondary and tertiary information in collaboration with the interdisciplinary team, family members, health care providers, and significant others to develop a comprehensive understanding of the Veteran's health care needs. Ensure that appropriate releases of information are obtained and that confidentiality requirements are observed.
• Health Care Team and Veteran Communication: Work closely with Veterans and assist in communicating Veteran care preferences and personal health goals to health care providers and to facilitate shared decision making of the Veteran's care. Serve as a resource for education and support for Veterans and families, and identify appropriate Veteran-centered supports.
• Community Services, Outreach, and Referrals to Support Veteran's Care Plan: Develop the Veteran's SSVF health care plan with an emphasis on community services, outreach, and referrals needed for the Veteran. Develop the plan in collaboration with the interdisciplinary treatment team, Veteran, family members, and significant others; incorporating measurable goals. Regularly review care plan goals with the Veteran, conduct ongoing non-clinical barrier assessments, and provide resources and referrals needed to support adherence. Evaluate effectiveness of resources and referrals provided and make modifications to ensure provision of high-quality care and interventions. Monitor and document progress and provide updates to the team as appropriate.
• 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. Modify services to meet the Veteran's needs and coordinate services with other organizations/programs to assure provision of complementary and comprehensive services. Represent the program in contacts with other agencies and the public. Coordinate additional supportive services to ensure Veteran and caregivers are linked to supportive services, including but not limited to, housing, financial benefits, and transportation. Coordinate referrals to VA, community health clinics, and other programs needed to ensure access to health care. Follow the care plan to facilitate adherence, and collaborate with community providers to maximize use of VA and community resources. Act as an advocate for the client, integrating the Veteran's cultural values into the care plan. Assist Veteran to identify methods to monitor progress toward meeting health goals. Provide ongoing follow up.
• Health Education: Educate Veterans and caregivers on available services and assist with referrals based on Veterans preferences. 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 support as needed based on identified needs.
• Interdisciplinary Collaboration, Coordination and Consultation: To promote the highest level of quality car, collaborate with the health care provider, interdisciplinary care team, and the SSVF team, regularly consulting on ongoing assessment of Veteran needs. Act within professional boundaries and roles appropriately, respecting the roles of others involved in care and services.
• Risk Management & Infection Control: Complete required training including: Safe from Harm, Blood Borne Pathogens, The Salvation Army's Case Work Certification Program, Confidentiality, Ethics, Suicide Prevention, and all SSVF Health Care Navigator training. Report any accidents or injuries to self or clients and complete appropriate documentation. Follow risk management plan, infection control practices (i.e., hand washing, universal precautions/isolation procedures, and precautions), follow protocols specific to COVID-19 prevention, and all safety protocols vital to staff and Veteran safety.
• Confidentiality, Computer Security, and Ethical Practice: Adhere to ethical standards of practice and principles of confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., critical incident reporting, HIPPA, Duty to Warn). Ensure client confidentiality is maintained in accordance with established procedures and regulations.
• Continuous Quality Improvement (CQI) and Systems Improvement: Participate in expanding knowledge related to health care navigation with the Veteran population. Collaborate with supervisors to review research-based best practice and make suggestions on improvements to HCN service delivery. Participate in case reviews and progress updates in team meetings. Submit monthly reports as required on activities and unmet needs. Attend in-service and outside trainings as requested. Assure service delivery in compliance with VA-SSVF program regulations, SSVF Program Guide, SSVF policies/procedures, The Salvation Army's policies/procedures, 38 CFR Part 62, and policies/procedures/waivers specific to COVID-19 as instructed by the VA-SSVF Program Office.
• Customer Service: Participate effectively in team meetings, case conferences, and related activities. Collaborate with multidisciplinary team members to enhance coordination of comprehensive Veteran care. Effectively communicate and utilize community agencies to facilitate continuity of care.
• Age, Development, and Cultural Needs of Veteran Clients: Consistent sensitivity to all Veteran's needs concerning age, developmental requirements and culturally related factors and consideration of age-related differences in the provision of care.

Minimum Qualifications:

The requirements listed below are representative of the minimal education, experience, certifications, skills, and/or abilities required for this position.

Education: Bachelor's degree required but years of experience noted below may substitute.

Experience: Prior experience performing medically based case management preferred, experience serving homeless population and Veterans preferred, and prefer experience with crisis intervention and community resources.

Certifications/Licenses: None.

Skills/Abilities: Advanced case management skills in a medical or medical case management environment and an ability to function independently while seeking supervisory consultation. Exercise sound judgment and initiative in day to day activities based on expertise accumulated through education, training, experience, and staying abreast of best practice literature. Competent in use of computer technology for documentation, date entry, and virtual technologies. Must concentrate mental and visual attention closely on work for sustained periods, employ critical thinking, and creative problem solving.

Skills/Abilities/Competencies & Key Performance Indicators: These are the skills, abilities, competencies, and key performance indicators that the employee is expected to demonstrate in the performance of their position and which is evaluated annually:

1. Collaboration & Team Work: Builds good working relationships, collaborates, and cooperates with staff, supervisors, managers, and other organizational departments, outside agencies, and other community partners. Works effectively as a part of a team to achieve organizational and program goals. Shows respect for others and values their contributions. Shares ideas and contributes to greater productivity in meeting shared goals.
2. Attendance & Timeliness: Consistent, good attendance, and punctuality are essential to satisfactory performance of job duties. Demonstrates the ability to prioritize tasks and manage work effectively. Completes work on time and meets deadlines. Responds promptly to supervisory and management requests.
3. Communication: Communicates with co-workers, supervisors, managers, clients, vendors, and community partners in a cooperatively respectful professional manner. Listens effectively to the ideas and perspectives of others to seek understanding. Expresses thoughts and ideas easily in groups, teams, and one on one conversations. Written and verbal communications are professional, clear, concise, and articulate relevant information using Standard English. Ability to communicate using terminology and language unique to The Salvation Army and SSVF program. Demonstrates effective presentation and public speaking skills.
4. Financial Impact: Values, guards, and uses efficiently, the assets and resources of The Salvation Army and the SSVF program, including grant funds. Completes annual fraud prevention training and follows fraud prevention and risk management protocols. Initiated an idea that could be implemented to reduce operational costs/expenses or that could potentially increase revenue for the program or The Salvation Army.
5. Flexibility & Adaptability: Accepts change in a positive manner, recognizing it as a normal part of organizational and program growth. Views change as an opportunity rather than a setback. Handles changes in operational protocols or service delivery in a positive manner while demonstrating an ability to adapt to the changing needs of the organization and program.
6. Initiative: Perceives and proactively recommends improvements or solutions to program processes, problems, or barriers. Respectfully asks appropriate questions regarding organizational and program processes while seeking resolution of issues or concerns. Demonstrates ability and willingness to utilize available training and information sources to find answers and solutions and shares suggestions with others. Consistently focused on quality improvements in the completion of one's own work and the overall program. Can work autonomously at a high level without the need for continual supervision. Is a self-starter.
7. Innovation & Creativity: Demonstrates openness to new ideas, methodologies, concepts, and solutions. Generates new ideas and solutions for continuous quality improvements and to measure program effectiveness and outcomes. Ability to utilize critical thinking to find solutions to complex problems.
8. Self-Development: Continuously learns new skills to contribute to the organization and program. Seeks opportunities to grow and learn new things in the performance of job duties and to develop competency in the position, as well as, competencies needed to advance in the organization/program. Attends available continuing education classes, webinars, and workshops, relevant to the position, and demonstrates the initiative to perform independent study/research on topics relevant to the program, position, and quality improvement. For all SSVF Staff self-development performance includes: (1) Cultural Competency Skills & Competencies: Adaptable in culturally diverse environments, respect for cultural differences, and comfort level working with "military" and "veteran" cultures; and (2) Community Practice Skills & Competencies: Engage with others, form collaborative alliances, influence, motivate, manage change, and address barriers. Plan interventions to address program and community need using best practices.
9. Service Orientation: Provides appropriate services and customer service to the target population. Presents a friendly, approachable attitude to the target population, co-workers, supervisors, other departments, and community partners. Listens and acknowledges problems and issues and resolves them in a timely and satisfactory manner. Demonstrates the ability to engage others in a helpful manner and displays empathy and patience. Must demonstrate The Salvation Army's Core Values & Caring Principles in Social Services": Belief in Human Potential, Dignity and Respect, Cultural Competence, Social Justice, Integrity and Accountability, and Partnership and Collaboration; and must adhere to "The Salvation Army's Social Services Code of Ethics" policy in the execution of job responsibilities.
10. Technology Proficiency & Technology Change: Learns, adapts quickly, and is proficient with new technologies and related procedures and policies regarding computers, audiovisual equipment, information management systems, and with other project management, information, and organization systems.
11. Works Efficiently at a High Quality: Competent in time management, organization of work time, and effectively balancing multiple priorities. Works well independently and in teams. Meets all productivity requirements and deadlines required of the position while meeting quality standards at all times. Strives to eliminate inefficient work habits and processes and improve productivity.

Supervisory Responsibility: None.

Physical Requirements:

1. Sit, walk, stand, bend, squat, climb, kneel, and twist on an intermittent or occasional basis.
2. Grasp, push, pull objects, such as reference materials, files, file cabinet drawers, and reach overhead.
3. Operate telephone and electronic communication devices.
4. Operate other office equipment including personal computer, copier, fax machine, and scanning equipment.
5. Ability to lift up to 25 lbs. occasionally.

Travel: Ability to travel up to 50% of the time with varied travel requirements including local, out of town but in State full day travel, and periodic overnights.

Driving: Must possess a valid driver's license in the state of residence. Must be approved through The Salvation Army Fleet Safety Program to drive either a Salvation Army or personal vehicle on Salvation Army business. For use of a personal vehicle appropriate insurance must be maintained. Must meet the agency's drug free workplace policy and pass a background check.

Working Conditions: Work conditions are varied with some work performed in the office or in the community. Work is other than routine with frequent interruptions and changing priorities. Deadlines are a regular part of the job. Under direction where definite objectives are established, must plan and arrange a significant portion of own work, referring only unusual cases to supervisors or others, and possess the ability to prioritize work.

Other Requirements: Must pass a background check and meet requirements of the agency's drug free workplace policy. The SSVF program provides services to vulnerable adult households. Applicants with felony convictions for child abuse, endangerment, or crimes against persons, cannot be considered. Must be able to adhere to infection control and pandemic control and prevention guidelines.

All employees recognize that The Salvation Army is a church and agree that they will do nothing as an employee of The Salvation Army to undermine its religious mission.

The Salvation Army Mission: The Salvation Army, an international movement, is an evangelical part of the universal Christian church. Its message is based on the Bible. Its ministry is motivated by the love of God. Its mission is to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination.

The Salvation Army is an equal opportunity employer. Candidates who are back-to-work, US Veterans, people with disabilities, people who have been impacted by the justice system, and/or people without a college degree are encouraged to apply.