Health Care Navigator/Case Manager

JOB PURPOSE:

Health Care Navigators provides services that include connecting Veterans to VA health care benefits or community health care services where Veterans are not eligible for VA care. Health care navigator's provide case management and care coordination, health education, interdisciplinary collaboration, coordination, and consultation, and administrative duties. Healthcare Navigators work closely with the Veteran's primary care provider and members of the Veteran's assigned interdisciplinary treatment team.

The health care navigator possesses excellent judgment and has at least two years of experience in a healthcare or social services area of practice. The health care navigator will act as a liaison between the Veteran Supportive Services Program and VA or community medical clinic and works with a population of Veterans with complex needs who require assistance accessing health care services or adhering to health care plans.

The health care navigator works closely with the Veteran's assigned multidisciplinary team, including medical, nursing, and administrative specialists, and case management personnel. The health care navigator works within this team to provide timely, appropriate, Veteran centered care equitably. The health care navigator works collaboratively with the team and the Veteran to identify and address systems challenges for enhanced care coordination as needed.

ESSENTIAL JOB RESPONSIBILITIES:

A. Non-Clinical Assessment

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. The assessment should highlight 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. The initial assessment will be completed as specified by the policy. An assessment may be accomplished through virtual technology.

B. Health Care Team and Veteran Communication

The Health Care Navigator works closely with Veterans to assist them in communicating their preferences in care and personal health-related goals to facilitate shared decision making of the Veteran's care. The Health Care Navigator 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.

C. Case Management and Care Coordination

The Health Care Navigator provides comprehensive case management to Veterans and their families who are homeless or at risk of homelessness. The Health Care Navigator acts as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes.

The Health Care Navigator will conduct initial intake meeting with Veteran. Evaluate individual and family needs. Complete services plan with Veteran including housing and other related needs.

Coordinate and monitor services, including comprehensive tracking of Veteran activities in relation to service plan and Housing Inspections. Document detailed case notes, daily; maintain comprehensive client files. Meet regularly with the Lead Case Manager to staff case load. Prepare report as requested by Lead Case Manager, Program Manager and/or Quality Assurance.

The Health Care Navigator modifies services to meet the needs of Veterans best and coordinates services with other organizations and programs to assure such services are complementary and comprehensive; directs activities to maximize effectiveness, efficiency, and continuity of care for Veterans; provides case management services to Veterans serves as the liaison to VA and community health care programs and represents the program in contacts with other agencies and the public.

The Health Care Navigator helps coordinate supportive and additional services with the Veteran. The Health Care Navigator ensures and links Veterans and caregivers to supportive services, which include, but are not limited to, housing, financial benefits, transportation.

The Health Care Navigator serves as the subject matter expert on community resources related to the needs of the Veteran. The health care navigator collaborates with other providers in the ongoing reassessment of the Veteran's health care needs. The health care navigator is responsible for educating the Veteran and caregiver of the available services and assisting them in establishing the appropriate referrals based on the Veteran's preference.

The Health Care Navigator will determine the needs, strengths, limitations, and preferences of each Veteran and will engage in problem solving to identify and reduce barriers to care. The health care navigator will educate the Veteran and family on the available options for acquiring knowledge and skills for managing health and wellness.

The Health Care Navigator coordinates referrals to VA, community health clinics, and other programs needed to ensure access to health care. The Health Care Navigator follows the care plan to facilitate adherence and collaborates with community providers to maximize the use of VA and community resources.,

The Health Care Navigator acts as an advocate for the client, integrating the Veteran's cultural values into their care plan. The health care navigator assists the Veteran in identifying methods to monitor progress toward meeting health goals and provides ongoing follow up.

D. Health Education

The Health Care Navigator assists in identifying the Veteran and family's health education needs and provides education services and materials that match the health literacy level of the Veteran. The health care navigator provides ongoing education support as needed to the Veteran and family member. The Health Care Navigator assists in identifying VA and community resources to prevent disease and promote self-care. For specialized health education outside of the Health Care Navigator's scope of practice, the health care navigator will refer to Veterans and families to the appropriate interdisciplinary team member for identified health education needs.

E Interdisciplinary Collaboration, Coordination and Consultation

To ensure the best possible care, the Health Care Navigator collaborates with other disciplines involved in providing care. The Health Care Navigator regularly consults with other team members and appropriately assesses and addresses the needs of the Veteran. The Health Care Navigator understands the different roles within the interdisciplinary team and acts within professional boundaries. The health care navigator will adhere to ethical principles about confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., critical incident reporting, HIPPA, Duty to Warn).

F. Administrative Duties and Systems Improvement

The Health Care Navigator participates in expanding the knowledge related to health care navigators and the Veteran population. The health care navigator identifies systemic barriers within the organization, communicates with organizational leadership about these barriers, and works collaboratively to find viable solutions. The health care navigator assists in developing policy, procedures, and practice guidelines related to the specialty program using knowledge gained from research or best practices. The Health Care Navigator develops relationships with community leaders, VA staff, and other referral networks. The health care navigator provides subject matter expert consultation to staff and community providers on the specialty area of practice. The Health Care Navigator may develop evaluation components and outcomes indicators and report those evaluation results to VA and organizational leadership.

Meet regularly with Program Director to staff case load. Provide on-going program evaluation and recommendations to Program Director for continuous growth and quality.

Perform other duties as assigned.

ESSENTIAL QUALIFICATIONS:

EDUCATION: Master's level social worker or equivalent education and experience is preferred.

EXPERIENCE: 1+ year's case management experience; 3+ years preferred. Knowledge of VA Programs, facilities, and community preferred.

LICENSES: LMSW, LBSW, LMFT preferred. Driver License with clear record required.

VEHICLE: Must have daily use of a vehicle without prior notice. Must maintain current registration and current automobile liability insurance that is in compliance with Texas law. Must be available and willing to transport clients to various locations and with such frequency as the business need dictates. Mileage reimbursement provided.

ATTENDANCE: Must maintain regular and acceptable attendance at such level as is determined in the

employer's sole discretion. Must be available during the stated service hours.

OTHER: Must be available and willing to travel to various locations and with such frequency as the business need dictates. Must be available and willing to work nights, weekends and holidays as required to meet business needs. Must not pose a direct threat or significant risk of substantial harm to the safety or health of himself/herself or others.

Endeavors has a longstanding practice of providing a work environment that is free from all forms of employment discrimination, including harassment, because of race, color, sex, gender, age, religion, national origin, marital status, sexual orientation, gender identity, genetic information, disability, military or veteran status, or any other characteristic protected by law. We recruit, hire, employ, train, promote, and compensate individuals based on job-related qualifications and abilities.

Endeavors also provides reasonable accommodation to qualified individuals with disabilities or based on a sincerely held religious belief, in accordance with applicable laws. If you need to inquire about an accommodation, or need assistance with completing the application process, please email hr@endeavors.org or speak with your recruiter.

Endeavors is dedicated to offering reasonable accommodations for individuals with disabilities. If you are a qualified candidate with a disability and need help submitting your application online, please reach out to us at recruiting@endeavors.org. If you are chosen for an interview, we will provide further details on how to request accommodations for the interview process.