GENERAL DESCRIPTION OF ASSIGNED DUTIES
- Conducts assessment of the Veterans in collaboration with the case management team, the Veteran, family members, and significant others.
- Act as a liaison between the SSVF grantee 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 case management team, including medical, nursing and administrative specialists.
- Work within SSVF team to provide timely, appropriate, Veteran centered care in an equitable
- Work collaboratively with healthcare team and Veteran to identify and address system challenges for enhanced care coordination as needed.
- Conducts assessments of the Veteran in collaboration with the case management 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.
- Assessments should highlight the Veteran’s strengths, limitations, risk factors and internal / external supports and service needs in order to optimize the Veteran’s ability to access and maintain health care
- Initial assessments will be completed as specified by the policy of the SSVF grantee and may be accomplished through virtual technology.
HEALTH CARE TEAM AND VETERAN COMMUNICATION
- Work closely with Veterans to assist them in communicating their preferences in care and personal health-related goals, in order to facilitate shared decision making of the Veteran’s care.
- Serve as a resource for education and support for Veterans and families and help identify appropriate and credible resources and supports tailored to the needs and desires of the Veteran.
- Participate as needed in the development of the Veteran’s care plan; with emphasis on community services, outreach, and referrals needed for the Veteran.
- Review care plan goals with Veteran and conduct regular non-clinical barrier assessments and provide resources and referrals to address barriers as needed.
- Periodically review effectiveness of resources and make modifications as needed.
- Monitor Veteran’s progress, maintains comprehensive documentation, and provides information to the treatment team members when appropriate.
- 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 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.
- Coordinate 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.
- Serve as a liaison to VA and community health care programs; and represent the SSVF program in contacts with other agencies and the public.
- 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 their SSVF housing Case Manager.
- Serve as the subject matter expert on community resources related to the needs of the Veteran.
- 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 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 DUTIES AND SYSTEMS IMPROVEMENT
- Assist in developing policies and procedures related to this specialty and the program.
- Maintain accurate and detailed case notes.
- Enter relevant data into HMIS 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 VA and organizational leadership.
- Knowledge of social service resource systems and self-help intervention strategies.
- Independently counsel populations of mental health, substance abuse, and homeless individuals
- Knowledge and skills in handling substance abuse and mental health issues.
- Knowledge of public benefits and financial resources available in the community.
- Ability to successfully develop relationships utilizing motivational interviewing techniques.
- Crisis intervention and conflict resolution skills including use of motivational interviewing, harm reduction approach, and trauma-informed care.
- Knowledge of family budgeting and money management.
- Thoroughness and accuracy with data collection, entry and quality control in a web-based database.
- Patience/tolerance and tact/diplomacy.
- Clear/firm-yet-flexible boundaries, consistent energy level and positive demeanor.
- 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 and accountable for work time and other agency resources.
- Quality control: demonstrates accuracy and thoroughness, monitors own work to ensure quality and applies feedback to improve performance.
- Well organized: able to effectively manage multiple assignments to meet project deadlines.
- Familiar with health care systems, specifically within the Veteran’s Health Administration / VA
- Bachelor’s degree in social work, psychology or related healthcare field; Graduate degree preferred.
- 1-3 years’ experience in the field of primary or behavioral health care.
- Experience working with low income and/or homeless populations.
- Proficient computer skills, including Microsoft Office Suite (Outlook, Word and Excel)
- Proficient typing skills.
- Ability and willingness to work flexible hours to accommodate participants available during the evening or on weekends.
- Experience working in diverse settings with people across all socio-economic spectrums and a wide variety of personalities and roles – staff, residents, local agencies, contractors, lenders, etc.
- Access to reliable personal transportation required, including a DMV record that permits driver to be insured under automobile coverage.
- Must successfully pass a criminal background check.
- Licensed Clinical Social Worker; CNA; LPN; LMFT.
- Experience working with people in low-income subsidized housing arrangements and/or supportive housing housing programs.
- Bi-Lingual English Spanish
The physical demands described below are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk and hear. The employee is often required to sit and use their hands and fingers to handle or feel objects. The employee is occasionally required to stand, walk, reach with hands and arms, climb or balance, and stoop, kneel, crouch or crawl. Specific vision abilities required by this job include close vision.
The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. The employee must also have access to a reliable and operating vehicle in order to drive to client appointments.
Position begins asap. Work hours are Monday – Friday, 9-5 although there may be some night time or weekend hours on occasion to attend community events (post-COVID), meet with clients and landlords, or attend to emergent client and administrative needs. Starting salary is $23.00 – $26.00 per hour DOE with medical and dental benefits provided, as well as generous paid time off and mileage reimbursement. A background check will be conducted. Candidate must be willing to make at least a one-year commitment. This is not a remote position.
This position will work with our Supportive Services for Veteran Families Program enrolled veterans countywide, with the position being based out of our Santa Barbara office.
Send resume, cover letter and a list of three professional references to email@example.com. If we feel you are a good match for the position, you will be contacted to schedule an interview.
All qualified applicants will receive consideration for employment without regard to race; color; ancestry; national origin; religion/creed; sex/sexual orientation; gender; gender identity/expression, transition; political affiliation or beliefs; disability, medical condition, generic information, marital status; military/veteran status; pregnancy and conditions related thereto.; or any other characteristic protected by law (as defined by the California Fair Employment and Housing Act — Government Code Section 12900-12996), except where such discrimination is based on a bona fide occupational qualification.
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