Healthcare Navigator in RRH

East Oakland Community Project

JOB DESCRIPTION

Title: SSVF Health Navigator

Department: SSVF

Reports to: SSVF Manager

FLSA Status: Non-exempt

Salary – 60K – 65K

SUMMARY

The SSVF Health Navigator connects Veteran households to VA health care benefits or community health care services when they are not eligible for VA care. Working closely with the Veteran household’s primary care provider and members of the Veteran’s assigned interdisciplinary treatment team, the Health Navigator provides health navigation case management and care coordination as well as health education to identify and address system challenges. The SSVF Health Navigator acts as a liaison between Veteran households with complex health needs, and who require assistance accessing health care services, or adhering to health care plans, with the VA or a community medical provider.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Assessment

• Conducts an initial assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others following SSVF policies and procedures.
• Establishes an understanding of 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.
• Highlights 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.

Communication

• Works closely with Veterans to assist them in communicating their preferences in care and personal health-related goals.
• Serves as a resource for education and support for Veterans and families and helps identify appropriate and credible resources and support tailored to the needs and desires of the Veteran.
• Participates in the development of the Veteran’s care plan with the interdisciplinary healthcare team, the Veteran, family members and significant others and ensures connections to community services.
• Regularly reviews care plan goals with the Veteran, addressing systemic barriers.
• Evaluates the effectiveness of the resources and referrals provided and makes appropriate modifications to ensure the provision of high-quality care and interventions.
• Maintains comprehensive documentation, and provides information to treatment team members when appropriate.
• Assists Veterans in identifying concerns or questions about their treatment or medications to develop open communication with the provider or treatment team.

Case Management and Care Coordination

• Provides comprehensive case management and care coordination across episodes of care.
• Coordinates referrals to the VA, community health clinics and other programs needed to ensure access to health care.
• Acts as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes.
• Modifies services to meet the needs of Veterans and coordinates services with other organizations and programs to ensure services are complementary, comprehensive and there is continuity of care for the Veteran.
• Serves as a liaison to the VA and community health care programs, and represents the program in contacts with other agencies.
• Ensures coordination with housing, financial benefits, transportation, etc.
• Educates the Veteran and caregiver of services.
• Acts as an advocate for the client, integrating the Veteran’s cultural values into their care plan.
• Assists the Veteran in identifying methods to monitor progress toward meeting health goals and provides ongoing follow up.
• Consults with other team members and appropriately assesses and addresses the needs of the Veteran.
• Participates effectively in team meetings, case conferences, and related activities. Collaborates with multidisciplinary team members in a manner that enhances the coordination of comprehensive Veteran care.
  Adheres to ethical principles about confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., critical incident reporting, HIPPA, Duty to Warn).

Health Education

• Identifies the Veteran and caregiver’s health education needs and provides education services and materials that match the health literacy level of the Veteran.
• Provides ongoing health education support as needed.
• Assists in identifying VA and community resources to prevent disease and promote self-care.
• Refers Veterans and caregivers to the appropriate interdisciplinary team member for specialized health education needs.

Administration

• Assists in developing policy, procedures, and practice guidelines related to health navigation and using knowledge gained from research or best practices.
• Develops relationships with community leaders, VA staff, and other referral networks.
• Develops client outcomes/indicators and reports those evaluation results to the VA and SSVF.
• Follows applicable regulations and instructions regarding access to electronic files, the release of access codes, and the use of electronic information.

QUALIFICATIONS

EDUCATION

• B.A. level social worker or equivalent education and experience are preferred.

EXPERIENCE

• At least 3-5 years of health navigation and case management experience.
• Understanding and/or experience working with Veterans and their households. Prior exposure to serving low income or families experiencing homelessness preferred.
• Knowledgeable about the dynamics of homelessness, including living with addictions, mental health issues and/or domestic violence.
• Knowledge of basic counseling and interviewing techniques. Motivational Interviewing experience/training preferred.
• Experience with client database systems.
• Demonstrated ability to maintain organized health navigation and case management files.
• Experienced in producing well written reports, memos and other correspondence in a timely fashion.
• Demonstrated experience de-escalating volatile situations with clients.
• Able to maintain a calm demeanor and communicate effectively with Veteran households and team members (verbal and written communication).
• Able to work in a culturally diverse environment.
• Strong team player and collaboration skills.

REASONING ABILITY

• Able to use utilize good judgement, think logically and make sound decisions. Able to outline realistic health navigation plans.
• Ability to work well under pressure.

COMPUTER SKILLS

• Experience working with computers and successful utilization of Word and Excel. Able to navigate the internet and retrieve resources and email.
• Familiarity with all applicable laws that protect printed and electronic files containing client sensitive data.

CERTIFATES, LICENSES, REGISTRATIONS

• Valid California Driver’s license and automobile insurance.

WORK ENVIRONMENT

• Monday - Friday 9:00 am - 5:30 pm some evenings, weekends, and holidays may be required.
• Up to 90% of the time may be spent working in the field with participants, in the car, outdoors, or in shelters. Other time will be spent in the office completing administrative and paperwork and meeting with the OTVC Program Manager.
• Adheres to health and safety standards.