Job Purpose
The overall purpose of the Community Resource Specialist / Case Manager is to work directly with the Veterans on a variety of issues to assist them in identifying and overcoming challenges to accessing the healthcare system or adhering to recommended healthcare plans. The incumbent will also be responsible to provide comprehensive case management, financial counseling and assistance to prevent veterans and their families from becoming homeless.
Qualifications
- BSW is required, MSW preferred
- Minimum two years' experience navigating healthcare and the healthcare systems
- Experience delivering services to SUD, COD, or homeless population preferred
- Valid driver's license and proof of current insurance
- Experience working with Veterans is preferred
Duties and Responsibilities
Community Resource Specialist
Conduct non-clinical assessments of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant othersWork closely with Veterans to assist them in communicating their preferences in care & personal health-related goals to facilitate shared decision making of the Veteran's careServe as a resource for education and support for Veterans and families and help identify appropriate & credible resources and support tailored to the needs & desires of the VeteranMay participate in the development of the Veteran's care plan; however, the healthcare navigator's emphasis is on community services, outreach, and referrals needed for the VeteranRegularly review care plan goals with the Veteran, conduct regular non-clinical barrier assessments, and provide resources and referrals needed to support plan adherencePeriodically evaluate the effectiveness of the resources and referrals provided and make appropriate modifications to ensure the provision of high-quality care and interventionsMonitor Veteran's progress, maintain comprehensive documentation, and provide information to treatment team members when appropriateAssist the Veterans in identifying concerns or questions about their treatment or medications to develop open communication with the provider or treatment teamProvide 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 outcomesServe as the liaison to VA and community health care programs, and represent the program in contacts with other agencies and the publicDetermine the needs, strengths, limitations, and preferences of each Veteran and engage in problem-solving to identify and reduce barriers to careAct as an advocate for the client, integrating the Veteran's cultural values into their care planOther duties as assigned or requestedCase Management
Delivery of case management and supportive services to homeless veterans; maintain case filesReview Intake Specialist's screen, matrix, categorization and comprehensive assessmentMake determination of supportive service needsDevelop a Housing Identification and Stability PlanProvide housing stability counseling :Awareness and referral to rental and rent subsidy programs
Awareness and referral to housing assistance programsEducate participants on supportive service availability and client rights, including :Fair Housing
Landlord tenant lawsLease termsRent delinquencyResolution or intervention of mortgage delinquencyHome maintenance and financial managementDevelop and monitor Single Coordinated Care Plan for participantsRequest temporary financial assistance after obtaining approval by Program ManagerMake program referrals and establish linkages with appropriate agencies / service providers to assist participants obtain needed supportive services, including, but not limited to :Non-compensation benefits from the VA
Vocational and Rehabilitation CounselingEmployment and Training ServicesEducational AssistanceHealthcare ServicesChildcare Providers and AssistanceProtective Payee ServicesLegal ServicesDaily Living ServicesDirect Financial AssistanceEmergency AssistanceExecute participation agreements with participantsMaintains accurate and timely records of clients through detailed case noting of assessments, contacts, and progress using required case management forms and maintains required HMIS recordsCoordinate with additional staff to provide pick-up / drop-off transportation services and administer bus ticketsProvide financial counseling and assist participant in developing personal budgetCreate a discharge plan for participants including referral optionsOther duties as assigned or requested