SSVF FAMILY SUPPORT SPECIALIST

Description

SUMMARY:

The SSVF Family Support Specialist, reporting to the Director of VA Services, provides Veteran centered housing navigation, health care navigation, and case management to eligible Veteran households who are experiencing homelessness or are at imminent risk of homelessness. This position is based in Santa Fe (hybrid) and serves Santa Fe and surrounding northern New Mexico communities. Hybrid means a combination of office-based, field-based, and community-based work as scheduled with the Director of VA Services. The SSVF Family Support Specialist helps Veterans and their families obtain and keep safe, stable, and affordable permanent housing, and connects them to VA health care or community health care when they are not enrolled in or eligible for VA care.

This position supports the U.S. Department of Veterans Affairs (VA) Supportive Services for Veteran Families (SSVF) program's mission of rapidly re-housing homeless Veteran families and preventing homelessness among very low-income Veteran households. The SSVF Family Care Navigator uses Housing First, trauma-informed, and strengths-based practices and complies with SSVF requirements, SFRC policies, and applicable federal regulations, including 38 U.S.C. § 2044 and 38 CFR Part 62. Health care navigation is non-clinical: the SSVF Family Support Specialist does not provide direct health care, mental health counseling, or treatment recommendations.

Requirements

DUTIES AND RESPONSIBILITIES:

Eligibility, Assessment, and Care Coordination

• Determine eligibility for SSVF services, collect and verify required documentation, and recertify participant eligibility at required intervals.
• Complete comprehensive, non-clinical assessments of each Veteran household to identify housing barriers, health care needs, immediate needs, strengths, risks, and resources.
• Develop individualized, measurable Housing Stability Plans with each Veteran and household, including health care access goals.
• Provide ongoing case management focused on housing stability, health care access, income, self-sufficiency, and long-term housing retention.
• Maintain regular contact with assigned Veterans in the office, community, home, shelter, and other appropriate settings.
• Monitor progress toward goals and update service plans as circumstances change.
• Use motivational interviewing, Housing First, strengths-based, and trauma-informed approaches.
• Respond to housing crises, safety concerns, and other urgent situations, and refer to emergency, crisis, and suicide prevention resources as needed.

Housing Navigation: Rapid Re-Housing and Homelessness Prevention

• Help Veterans experiencing homelessness identify, apply for, and secure permanent housing that meets their needs and preferences.
• Help Veterans at imminent risk of homelessness keep their current housing whenever possible.
• Recruit and maintain relationships with landlords, property managers, housing authorities, and real estate professionals, and explain SSVF services and benefits to new landlords.
• Maintain an up-to-date list of available units and housing resources in the service area.
• Help Veterans complete housing applications, obtain identification and required documents, and prepare for landlord screenings.
• Negotiate with landlords to address screening barriers, lease terms, and move-in costs.
• Coordinate temporary financial assistance, such as rental assistance, security deposits, utility assistance, and moving costs, in line with SSVF requirements.
• Conduct or coordinate move-in unit inspections for habitability, as required.
• Support landlord–tenant communication to prevent and resolve lease issues.
• Coordinate with HUD-VASH, public housing authorities, the Continuum of Care coordinated entry system, and shelters, including collaborative case management for co-enrolled Veterans.
• Follow up after housing placement to support stability and prevent returns to homelessness.

Health Care Navigation

• Assist Veterans with enrolling in VA health care, including mental health and substance use care, by working with the Santa Fe VA Community Based Outpatient Clinic and the New Mexico VA Health Care System.
• Connect Veterans who are not eligible for or not interested in VA health care to community health care, including Medicaid, Medicare, marketplace coverage, and community clinics.
• Help Veterans schedule and keep medical, behavioral health, and substance use treatment appointments, and arrange or provide transportation per SFRC policy.
• Coordinate with the Veteran's primary care provider and VA care team, with the Veteran's written consent.
• Identify health-related barriers to housing placement and retention, such as untreated conditions, medication access, disability, or hospital discharge, and work with the SSVF team to resolve them.
• Help Veterans understand provider instructions, prepare questions for appointments, and follow their health care plans.
• Provide health education on wellness, preventive care, and how to use the health care system.
• Help Veterans access durable medical equipment, prescriptions, and other health-related resources through their providers and benefits.

• Coordinate with hospitals, emergency departments, and treatment programs on discharge planning for Veterans who are homeless or at risk.

Benefits, Resources, and Referrals

• Help Veterans apply for VA benefits and other public benefits, including disability compensation, pension, SNAP, Medicaid, SSI/SSDI, and income supports.
• Connect Veterans to employment, education, legal assistance, child care, fiduciary and representative payee services, transportation, and other resources.
• Make referrals based on identified needs and follow up to confirm that Veterans connect with services.
• Share information with VA and community partners only with proper consent and in line with confidentiality requirements.

Documentation, Data, and Compliance

• Maintain accurate, timely, and complete participant records in line with SSVF requirements and SFRC policies.
• Document assessments, contacts, service plans, referrals, housing and health care navigation activities, financial assistance, and outcomes.
• Enter required data into HMIS, VA/SSVF systems, and SFRC systems within required timelines.
• Make sure documentation supports eligibility, services delivered, expenditures, and outcomes.
• Protect the confidentiality of Veteran and household information in line with applicable laws, VA requirements, and SFRC policies.
• Participate in file reviews, quality assurance, audits, and VA monitoring visits.

Collaboration and Community Engagement

• Participate in case staffing, team meetings, supervision, and interdisciplinary coordination.
• Do outreach to identify Veterans who are homeless or at imminent risk of homelessness.
• Represent SFRC and the SSVF program professionally in community meetings, coalitions, and resource fairs.
• Work closely with other SSVF Family Support Specialists, outreach staff, financial assistance staff, and the Director of VA Services.

Training and Quality Improvement

• Complete required VA, SSVF, and SFRC training, including SSVF health care navigation and professional boundaries training.
• Maintain current knowledge of SSVF policies, the SSVF Program Guide, and evidence-based practices.
• Use supervision to address complex cases, ethical issues, safety concerns, and service delivery challenges.
• Take part in program evaluation and continuous quality improvement.

Performance Expectations

• Engage eligible Veteran households promptly.
• Complete assessments and service plans on time.
• Place Veterans experiencing homelessness in permanent housing and prevent homelessness for those at imminent risk.
• Increase housing stability and retention.
• Increase Veteran enrollment in and connection to VA or community health care.
• Connect Veterans to income, benefits, and other stabilizing resources.
• Keep documentation and data entry accurate and timely.

Work Environment

• Hybrid position based in Santa Fe, combining office, field, and community-based work.
• Regularly meets Veterans in homes, shelters, temporary housing, VA and community health care facilities, and other community settings.
• Requires flexibility to respond to urgent housing needs, and may occasionally require work outside regular hours.
• May work with people experiencing significant housing instability, physical and mental health conditions, substance use, financial hardship, or other complex needs.
• Performs other duties as assigned.

MINIMUM QUALIFICATIONS:

Skills/Knowledge/Abilities:

• Knowledge of homelessness prevention, rapid re-housing, and Housing First.
• Knowledge of VA health care, VA benefits, HUD, public housing, rental assistance, and community housing resources.
• Understanding of health care systems, including the Veterans Health Administration, Medicaid, and Medicare.
• Awareness of PTSD, traumatic brain injury, substance use, and other conditions common among Veterans, to provide informed and respectful support.
• Ability to conduct assessments, develop service plans, coordinate services, and document progress.
• Ability to build positive relationships with Veterans, families, landlords, VA staff, health care providers, and community partners.
• Ability to maintain professional boundaries and work within the non-clinical scope of SSVF health care navigation.
• Strong interpersonal, communication, organization, and problem-solving skills.
• Ability to work independently and as part of a team.
• Ability to protect confidential information.
• Ability to use computers, HMIS, electronic records, email, and standard office software.
• Ability to respond calmly and appropriately in stressful or crisis situations.
• Respect for diverse backgrounds, identities, and Veteran culture.
• Bilingual/bicultural (English/Spanish) preferred.

Education and Experience:

• Bachelor's degree in Social Work, Human Services, Psychology, Sociology, Counseling, Public Health, Nursing, Public Administration, or a related field; or an equivalent combination of education and relevant experience.
• At least two (2) years of experience in health care, case management, housing services, social services, or a related area.
• Experience serving people experiencing homelessness or housing instability, Veterans, or other vulnerable populations preferred.
• Experience with SSVF, HUD-VASH, rapid re-housing, or homelessness prevention preferred.
• Experience with health care navigation, care coordination, or VA health care enrollment preferred.
• Experience working with landlords, property management, or public housing systems preferred.
• Experience with HMIS or VA/SSVF data systems preferred.
• Valid New Mexico driver's license, clean driving record, reliable transportation, and current auto insurance.
• Ability to travel throughout the service area.