Medical Outreach Case Manager

Position Summary

FACETS is seeking a mission-driven Medical Outreach Case Manager to join the team at Bailey’s Community Shelter and support coordinated outreach efforts across Region 2. The Medical Outreach Case Manager provides street-based and site-based case management to individuals experiencing homelessness with complex medical, behavioral health and social needs. The Medical Outreach Case Manager works as part of an interdisciplinary Homeless Healthcare Program (HHP) team that includes Fairfax County’s Community Services Board and Health Department, to engage unsheltered and sheltered individuals, coordinate access to primary and specialty care, support continuity of care, and address social determinants of health to improve health outcomes and housing stability.

The Medical Outreach Case Manager meets clients where they are, visiting known encampments, shelters, drop-in centers, other community locations, and responds to service requests from first responders, county agencies, businesses, and community members.

FACETS is a non-profit organization that opens doors by helping parents, their children, and individuals who suffer the effects of poverty in Fairfax County. We meet their emergency needs through our wrap around services and community partnerships and help individuals and families experience safe and stable housing after years of uncertainty and instability. We strive to ensure that every person in our community has a place they can call home.

Here at FACETS, every team member plays a role in making a difference in the lives of our most vulnerable neighbors.

• Conduct proactive outreach in encampments, shelters, drop-in centers, and other community locations to engage individuals experiencing homelessness.
• Establish initial contact and build trusting relationships with single adults experiencing unsheltered homelessness using a trauma-informed, harm-reduction, client-centered approach to meet their immediate needs and promote long-term stability.
• Distribute necessities such as clothing, hygiene items, non-perishable food, and other survival supplies to clients living outdoors or in places not meant for habitation.
• Refer clients to appropriate County and community-based services, including housing programs, employment assistance, public benefits (ex. Medicaid, SNAP), mental health support and substance use needs.
• Collaborate with the Fairfax County Health Department’s Homeless Healthcare Program and the Community Services Board’s PATH Team to coordinate access to physical and behavioral health services for individuals experiencing homelessness.
• Assess housing barriers faced by individuals experiencing homelessness or at-risk of homelessness to identify the client’s housing and support service needs.
• Develop individualized case management plans focused on housing acquisition, budgeting, and self-sufficiency, beginning with intake interviews to assess household needs, goals, and eligibility.
• Utilize the Housing First model to deliver housing stabilization services, prevent homelessness, and divert households from entering emergency shelters.
• Maintain consistent verbal and written communication with case managers, operations staff, tenants, landlords, referral sources, collaborating agencies, debtors, and creditors to ensure effective coordination and support.
• Advocate for and actively assist individuals in accessing a range of services, including mental health, intellectual disability support, substance use treatment, housing referrals, financial assistance, home based services, training, medical care, mentoring and socialization.
• Support clients in accessing essential resources such as housing assistance, food banks, clothing closets, and other community resources. Promote self-sufficiency by connecting them with sustainable support systems and encouraging the use of available resources.
• Work on an adjusted work schedule, including evenings and weekends, as necessary to meet program needs.

• Bachelor’s degree in the applicable human services field plus two years of professional social work/case management experience with…