Community Resource Specialist / Case Manager

Division: Bureau of Programs and Services

Department: Supportive Services for Veterans Famililes

Shift: 1st

Status: Full Time Non-Exempt

Reports to: SSVF Director / Assistant Director


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.

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 others
  • Work 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 care
  • Serve 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 Veteran
  • May 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 Veteran
  • Regularly review care plan goals with the Veteran, conduct regular non-clinical barrier assessments, and provide resources and referrals needed to support plan adherence
  • Periodically evaluate the effectiveness of the resources and referrals provided and make appropriate modifications to ensure the provision of high-quality care and interventions
  • Monitor Veteran’s progress, maintain comprehensive documentation, and provide information to treatment team members when appropriate
  • Assist the Veterans in identifying concerns or questions about their treatment or medications to develop open communication with the provider or treatment team
  • 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
  • Serve as the liaison to VA and community health care programs, and represent the program in contacts with other agencies and the public
  • Determine the needs, strengths, limitations, and preferences of each Veteran and engage in problem-solving to identify and reduce barriers to care
  • Act as an advocate for the client, integrating the Veteran’s cultural values into their care plan
  • Other duties as assigned or requested

Case Management

  • Delivery of case management and supportive services to homeless veterans; maintain case files
  • Review Intake Specialist’s screen, matrix, categorization and comprehensive assessment
  • Make determination of supportive service needs
  • Develop a Housing Identification and Stability Plan
  • Provide housing stability counseling:
    • Awareness and referral to rental and rent subsidy programs
    • Awareness and referral to housing assistance programs
  • Educate participants on supportive service availability and client rights, including:
    • Fair Housing
    • Landlord tenant laws
    • Lease terms
    • Rent delinquency
    • Resolution or intervention of mortgage delinquency
  • Home maintenance and financial management
  • Develop and monitor Single Coordinated Care Plan for participants
  • Request temporary financial assistance after obtaining approval by Program Manager
  • Make 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 Counseling
    • Employment and Training Services
    • Educational Assistance
    • Healthcare Services
    • Childcare Providers and Assistance
    • Protective Payee Services
    • Legal Services
    • Daily Living Services
    • Direct Financial Assistance
  • Emergency Assistance
  • Execute participation agreements with participants
  • Maintains accurate and timely records of clients through detailed case noting of assessments, contacts, and progress using required case management forms and maintains required HMIS records
  • Coordinate with additional staff to provide pick-up/drop-off transportation services and administer bus tickets
  • Provide financial counseling and assist participant in developing personal budget
  • Create a discharge plan for participants including referral options
  • Other duties as assigned or requested

Other Skills and Abilities

  • Ability to effectively communicate clearly and concisely in both oral and written format
  • Ability to reason logically given both concrete and variable factors
  • Must be flexible, and maintain composure in difficult situations
  • Ability to relate to and interact with individuals from diverse cultural backgrounds
  • Maintain confidentiality of all client information
  • Basic computer literacy skills in Microsoft Office products
  • Knowledge of Service Point is a plus


  • 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

Working Conditions

General office environment 25% of the time with 75% with home and hotel visits. The working environment is generally favorable. Lighting and temperature are adequate and there are no hazardous or unpleasant conditions. Work is performed in an office environment with standard office equipment available. Travel will be more than 50% and generally local.

Physical Requirements

Work is generally sedentary in nature and will require standing and walking for more than 50% of the time. There will occasionally be bending, lifting and carrying of up to 10-15 pounds.

Direct Reports

There are no direct reports.


Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.