Veterans Health Care Navigator - Social Worker

St. Paul, MN

Health Care Case Manager/Navigators are employed by MACV to provide services that include connecting Veterans to VA health care benefits or community health care services when Veterans are not eligible for VA care.  MACV health care navigators s provide support for case management, as well as care coordination, health education, interdisciplinary collaboration, coordination, consultation, and administrative duties. 

The Health Care Navigator will provide services that include:

  • Connect Veterans to VA health care benefits and/or community health care services, including behavioral health and substance use treatment providers.  
  • Coordinate with various partner agencies and work alongside staff across all MACV programs to ensure Veterans have access to care that meets their individual needs. 
  • Assist Veterans who are homeless or at risk of homelessness connect to health services that are often critical to maintain housing stability. 
  • Provide case management, care coordination, health education, interdisciplinary collaboration, consultation, and administrative duties. 
  • Coordinate with the Veteran’s primary care provider and members of the Veteran’s assigned interdisciplinary treatment team.
  • Provide care to Veterans statewide through in-person and virtual consultation with Veterans, care providers, and MACV case managers. In-person visits are often in the community setting, including shelters, hotels, transitional housing, hospitals, and private residences.  

Primary Duties and Responsibilities

  • Conducts non-clinical, bio-psycho-social assessments of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others.
  • 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.  Provide disposition of eligibility to community partners as needed.
  • Provides comprehensive health care related case management and care coordination by proactively supporting the Veteran to optimize treatment interventions and outcomes.
  • Follows the Veterans care plan to facilitate adherence, and collaborates with community providers to maximize the use of VA and community resources
  • 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. 
  • Regularly reviews care plan goals with the Veteran, conducts regular non-clinical barrier assessments, and provides resources and referrals needed to support adherence.
  • Contacts Veterans directly as needed to perform screenings from referrals in the community and website requests
  • 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 specialized health care case management services to Veterans serves, as the liaison to VA and community health care programs, as well as the MACV housing case managers, and represents the program in contacts with other agencies and the public.
  • Monitors Veteran’s progress, maintains comprehensive documentation, and provides information to treatment team members when appropriate.

 Key Skills and other Characteristics

  • Possesses excellent judgment and has at least two years of experience in a healthcare or social services area of practice or at least three years of experience if licensed as LSW.
  • Effectively communicates with and utilizes community agencies to facilitate continuity of care. Has regular contact and interaction with a variety of community agencies and resources. Collaborates with a variety of community agencies and engages in problem resolution activities.
  • Protects data and client privacy.
  • Anticipates and avoids potential causes of conflict, and activity promotes cooperation among co-workers. 
  • Sensitivity to all Veterans' individual needs concerning age, developmental requirements, and culturally related factors must be consistently achieved.
  • MACV operates with a Salesforce CRM, and utilizes the Homeless Veteran Registry as well.
  • Expected to function independently, exercising initiative and judgment in day-to-day activities, based on expertise accumulated through education, training, experience, and reference to relevant professional literature.
  • Participates effectively in team meetings, case conferences, and related activities.
  • Collaborates with multidisciplinary team members in a manner that enhances the coordination of comprehensive Veteran care.

Preferred Experience:

  • Master’s level social worker or BSW with 3+ years of experience, or equivalent. MACV will provide supervision. 
  • Ability to interact with supervisors, co-workers, Veterans, visitors, and the general public in a manner that is consistently courteous and cooperative and contributes to the effective operation of the case management program.
  • Thorough knowledge of community health care benefits and services including Medical Assistance, Minnesota Care, and Medicaid. Ability to assist clients to assist benefits with benefit claims when indicated.
  • Minimum two years of experience in a healthcare or social services area of practice.

Salary Range: 

LSW $52,000 - $60,000 LGSW $55,000 - $63,000 LICSW $60,000 - $68,000