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.
EXCEPTIONS TO THESE CRITERIA MUST BE APPROVED BY THE DEPARTMENT HEAD
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