Employment Achieve Human Services

ACHIEVE ENTERPRISE SERVICES, INC.

Position Title: (H2O) OUTREACH SPECIALIST

Department: HOUSING

Reports to: HOUSING MANAGER

GENERAL SUMMARY

The Housing and Health Opportunities (H2O) Outreach Specialist is responsible for identifying, engaging, and assisting individuals who meet eligibility requirements for the AHCCCS Housing and Health Opportunities (H2O) Program. Using a Housing First, trauma-informed, person-centered, and harm reduction approach, the Outreach Specialist conducts community-based outreach to individuals experiencing homelessness or housing instability through street outreach, institutional and hospital reaching, justice outreach, and collaboration with community partners.

The Outreach Specialist completes Health-Related Social Needs (HRSN) screenings, Housing Needs Assessments, provides community resource navigation, care coordination, benefits assistance, and transportation coordination to address immediate needs and reduce barriers to housing. The position works closely with healthcare providers, behavioral health providers, and community agencies to connect members with appropriate services and facilitates a seamless warm handoff to the Pre-Tenancy and Tenancy Sustaining (PTTS) Specialist for ongoing housing support.

The Outreach Specialist maintains accurate documentation in accordance with AHCCCS H2O, Medicaid, HMIS, and agency requirements while exercising sound judgment, professionalism, and strong community engagement skills when working with individuals experiencing homelessness, serious mental illness, substance use disorders, chronic medical conditions, justice involvement, and other complex needs.

MAJOR DUTIES/RESPONSIBILITIES

Outreach & Member Engagement

• Conduct community-based outreach to individuals experiencing homelessness or housing instability.

• Conduct street outreach in encampments, parks, shelters, meal sites, libraries, hospitals, community organizations, and other locations where unsheltered individuals may be found.

• Conduct institutional reach-in services with hospitals, behavioral health facilities, correctional facilities, and other institutional settings prior to discharge.

• Conduct justice outreach with correctional facilities, probation departments, parole officers, and reentry programs.

• Conduct hospital outreach to facilitate housing planning and reduce unnecessary hospital utilization. Utilize trauma-informed engagement techniques to establish rapport with members.

• Utilize Housing First principles to promote voluntary participation in services.

• Utilize Harm Reduction practices when engaging individuals actively using substances.

  Standard: Outreach activities are completed in accordance with AHCCCS H2O requirements and agency policy.

  Member Screening & Assessment

• Complete Health-Related Social Needs (HRSN) Screenings utilizing the approved assessment tool.

• Complete Housing Needs Assessments. Assess immediate health, housing, behavioral health, and social service needs. Identify barriers to obtaining and maintaining housing.

• Assess member safety and immediate crisis needs.

• Determine appropriate referrals for community resources.

• Coordinate completion of required program documentation.

  Standard: Assessments are completed accurately, timely, and in accordance with H2O requirements.

  Community Resource Navigation

• Assist members in obtaining identification documents.

• Connect members to mainstream benefits.

• Coordinate referrals to healthcare providers.

• Coordinate behavioral health services.

• Assist with AHCCCS enrollment or renewal through the agency Community Assistor.

• Connect members with food resources, transportation, employment services, legal assistance, veteran services, and other community resources.

• Coordinate peer support services when appropriate.

  Standard: Members are connected with appropriate community resources based on identified needs.

  Care Coordination

• Coordinate with healthcare providers.

• Coordinate with behavioral health providers.

• Coordinate with hospitals.

• Coordinate with correctional facilities.

• Coordinate with shelters.

• Coordinate with community partners.

• Coordinate with the Statewide Housing Administrator (HOM, Inc.).

• Coordinate with the AHCCCS H2O Program Administrator (Solari).

• Participate in multidisciplinary care coordination meetings.

  Standard: Care coordination activities support continuity of care and housing stability.

  Transportation

• Provide or coordinate non-emergency transportation to healthcare appointments, behavioral health services, housing appointments, and community resources in accordance with AHCCCS H20 policy.

• Document all transportation provided.

  Housing Navigation

• Educate members regarding available housing resources.

• Assist members with housing search preparation.

• Explain the H2O Program.

• Prepare members for transition to PTTS Services.

• Coordinate formal warm handoff to PTTS Specialist.

  Documentation

• Complete outreach documentation within one business day.

• Complete HMIS documentation. Maintain referral logs.

• Maintain Housing Needs Assessments.

• Maintain HRSN documentation.

• Document community coordination.

• Document transportation.

• Document warm handoffs.

• Maintain confidentiality and HIPAA compliance.

  Standard: Documentation meets AHCCCS, Medicaid, and agency standards and supports program compliance.

  Program Compliance

• Maintain knowledge of AHCCCS H2O requirements.

• Participate in supervision.

• Complete required training.

• Participate in Quality Assurance activities.

• Maintain compliance with Housing First and SAMHSA Permanent Supportive Housing Fidelity.

• Ensure services are not duplicated with other funding sources.

  Standard: 100% compliance with agency and contractual requirements as demonstrated through audits and supervisory review.

  Other Duties

• Participate in community outreach events.

• Participate in agency meetings.

• Participate in H2O team meetings.

• Assist with quality improvement initiatives.

• Perform other duties assigned by the Housing Manager.

• WORK ENVIRONMENT

  A. Supervision

  This position may have some supervisory responsibility.

  B. Confidentiality

  This position is exposed to highly confidential client information including behavioral health and physical health diagnosis and disability information, demographic information and client financial status. Employee must exercise ethical standards in handling confidential information.

• C. Mental Application and Responsibility

This position requires the ability to prioritize and organize workload, handle numerous tasks simultaneously and work under pressure. Must be able to interact with people in person at client homes and community settings, on the telephone, and must be able to interact with discretion and professionalism regarding confidential client information. Must be able to have sound judgment regarding behavioral health situations This position involves high level responsibility for administering company policies and procedures and a moderate level of responsibility for problem resolution and making clinical and administrative decisions. Staff must exercise sound judgment and ethical standards in handling direct care and supervisory duties.

D. Internal and Public Contacts

This position involves a high degree of interaction with staff, behavioral health and housing clients, family members, and other social service agency staff in the community on a regular basis

E. Conditions and Equipment

The work environment includes client home visits, clinical, and office settings for the provision of services and may include outside settings for outgoing and assisting customers with living skills, i.e., housekeeping, shopping, and personal hygiene. The employee must remain awake and alert throughout each work shift. Equipment operation includes general office equipment, computers, communication tools, and motor vehicles

F. Physical Demands

The work environment includes home and office setting. Staff must be able to walk up and down stairs and lift up to 25 pounds. The employee must complete trainings for safety and crisis intervention.

ABILITIES

• A. Language (Communication)

  Must be able to communicate clearly and effective orally and in writing; possess excellent organizational and time management skills. Bilingual English/Spanish verbal and written a plus

  B. Mathematical

  Basic mathematics is required for this position

  C. Reasoning

  Position requires basic understanding of working with people who have unique disabilities, basic understanding of crisis prevention and intervention and to assist in a recovery model or plan. Basic understanding of First Aid and CPR.

  D. Other

  Position requires a basic understanding of the Arizona State Housing Rules, Regulations and knowledge of Fair Housing and Landlord Tenant Act Laws and understanding of HUD eligibility guidelines and Housing Contracts are required. Maintain a high level of customer satisfaction. Comply with Fair Housing laws and Landlord/Tenant Act

  QUALIFICATIONS

  A. Education

  Associate's degree or higher in related field OR

  Three (3) to five (5) years case management experience in lieu of education

  B. Experience

  Requires Three (3) to Five (5) years of case management

  C. Other

• Must be over 21 years of age

• Must possess a valid driver's license

• Must be able to obtain a Level 1 Fingerprint Clearance Card

• Must be able to obtain valid certifications for Agency compliance within 90-days of employment

• Pass background check inclusive of Excluded Provider List System (EPLS) and the Health and Human Services (HHS) List of Excluded Individuals/Entities (LEIE)

DRUG-FREE WORK ENVIRONMENT

The Agency is committed to the development and maintenance of a drug free environment in accordance with the Drug-Free Workplace Act of 1988. Accordingly, the Agency will not tolerate any unlawful activity such as the possession, use, manufacture, distribution, and/or dispensation of a controlled substance on Agency-owned or controlled property. Any employee or client engaged in such prohibited conduct or convicted of a crime involving a workplace drug violation shall be subject to disciplinary action, up to and including termination. ACHIEVE Human Services, Inc. maintains and promotes a drug-free work environment and enforces a zero-tolerance policy for the use of alcohol, drugs and/or controlled substances.

HIPAA

Under the Health Information Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations, a Covered Entity under HIPAA is legally obligated to maintain the privacy of client health information that it creates or receives. The Agency recognizes the importance of keeping medical information confidential and is dedicated to meeting the HIPAA obligations. All information that we have about clients we consider to be confidential, and we maintain technical and administrative safeguards to protect against unnecessary use and disclosure of it. We expect our employees to respect our clients' instructions regarding any incidental exposure to protected health information. We are committed to supporting our clients in their efforts to comply with both state and federal privacy laws.

OSHA

Everyone has the right to a safe workplace. The Occupational Safety and Health Act of 1970 was passed to prevent workers from being seriously harmed at work or killed at work, and the law requires employers to provide their employees with working conditions that are free of known dangers. The Act created the Occupational Safety and Health Administration (OSHA), which sets and enforces protective workplace safety and health standards which are maintained by the Agency. OSHA also provides information, training and assistance to workers and employers. Workers may file a complaint to have OSHA inspect their workplace if they believe that the Agency is not following OSHA standards or that there are serious hazards in the workplace. An injured worker may undergo a drug screening.

REASONABLE ACCOMMODATION

The Agency strictly adheres to the requirements of the Americans with Disabilities Act (42 U.S.C. Sections 12101 et seq.). While the Agency strives to appreciate the special needs of its disabled employees and provide the necessary, reasonable accommodations, it remains the responsibility of each employee subject to the provisions of the Act to promptly and effectively communicate in writing the need for accommodation to the Agency.

EQUAL EMPLOYMENT OPPORTUNITY

ACHIEVE Human Services, Inc. does not discriminate on the basis of race, color, ethnicity, national origin, religion, sex (including gender and pregnancy), sexual orientation, gender identity or expression, sexual harassment, retaliation, genetic information, age (40 and over), marital status, membership or activity in a local human rights commission, status with regard to public assistance, or any other basis prohibited by statute in emplo...