TRC - Fox Veterans Case Manager & Suicide Prevention Specialist (Care Coordinator)

Fox Veterans Case Manager – Suicide Prevention Specialist (Care Coordinator) – JOB DESCRIPTION RESPONSIBLE TO : Fox Veterans Program Director FUNCTION: The care manager proactively contacts at-risk Veterans, connects them to counseling, and ensures follow-up care. Why this role matters: This is the core service delivery position, the backbone of the program. The Care Coordinator coordinates service provision for an assigned caseload of Veterans that meets the definition of the assigned program , regulatory body or funding entity. Advocates for and supports the client, engages with community agencies/health care providers , VA services and others on their behalf to ensure access to services needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: Must possess strong organizational skills and abilities in order to meet the multi-faceted needs of clients in a timely manner; Must possess an understanding of all applicable state and federal regulations related to health homes and a current working knowledge of social work best-practices; Must possess strong analytical skills to assess baseline progress and revise/establish goals/outcomes; Experience with individuals with disabilities and knowledge of rehabilitation and counseling services is essential; Comprehensive understanding of guiding principles of rehabilitation and counseling is critical; Must be self-directed and able to initiate and manage multiple responsibilities effectively and efficiently; Excellent verbal and written communication skills across various channels is paramount; Must be flexible and willing to work non-traditional hours as needed or assigned to meet client need; Physical condition commensurate with the demands of the job. MINIMUM QUALIFICATIONS: Bachelor’s degree in Social Work, Human Services, Nursing, or related field plus two (1) year of experience in care coordination, case management or related field. Experience with veterans services ,mental health, substance abuse, or medical frailties are strongly preferred. Valid driver’s license, use of personal vehicle, and willingness to travel for work is required. Proficient bilingual abilities in English and Spanish are desirable DUTIES OTHER DUTIES : Refer to Appendix Fox Veterans Case Manager – Suicide Prevention Specialist (Care Coordinator) – JOB DESCRIPTION APPENDIX OTHER DUTIES TECHNICAL: Primary responsibilities: 1. Conducts intake, eligibility verification, and needs assessments. 2. Administers suicide-risk screening tools (e.g., C-SSRS). 3. Creates and monitors Individualized Service Plans (ISPs). 4. Provides safety planning, crisis intervention, and referrals. 5. Maintains documentation for all veteran interaction 6. Maintains effective communications with clients, primary care physicians, substance abuse and mental healthcare providers, family, and collateral resources 7. Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure. 8. Coordinates care planning with other providers of services/resources to ensure goal-directed, collaborative care, including care transitions. 9. Works as part of a team; attends and participates in relevant team meetings to provide input/feedback around psychosocial and medical conditions/co-morbidities to review client status, update plans/goals, and review outcomes to further program goals. 10. Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field. 11. Provides linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan. 12. Monitors overall service delivery to clients to ensure coordination and continuity; advocates with service providers/resources as needed. 13. Provides crisis intervention and follow-up. 14. Provides self-help educational groups to clients. TECHNICAL: 1. Maintains responsibility for confidential and time sensitive information through the use of electronic management systems. 2. Effectively communicates with families, clients, staff and outside agencies via phone and email in a professional and timely manner. 3. Utilizes designated electronic systems to effectively manage work completion and remains with regulatory guidelines. 4. Seeks, reviews and recommends relevant updates and changes as needed through the appropriate channels. OTHER DUTIES: 1. Performs all other duties as assigned. REQUIRED TOOLS: 1. Care Coordinator will have access to the following items: a. Badge Access b. E-mail (internal and external account) c. Internet (with research browsing capabilities) d. Shared Drives e. Electronic Record keeping systems f. Agency Land Line g. Agency Cell Phone h. Others as needed or requested