Medical Outreach Case Manager

Title

Medical Outreach Case Manager

Kennedy Emergency Shelter

Assistant Director of Programs

$52K-$56K

Exempt

The Medical Outreach Worker is a key member of the street outreach team serving the Kennedy Emergency Shelter programs. This position provides intensive, health-focused case management and medical outreach services to individuals experiencing unsheltered homelessness. The Medical Outreach Worker collaborates closely with a Fairfax County Health Department Nurse Practitioner and other multidisciplinary partners to identify, engage, and build rapport with clients.

Responsibilities include providing transportation to medical and dental appointments, connecting individuals to a consistent "medical home," coordinating health services, and offering ongoing medical support. This role utilizes a trauma-informed, harm-reduction approach and meets clients where they are to promote trust, safety, and improved health outcomes.

This position requires strong interpersonal skills, flexibility, and comfort working in nontraditional environments, including campsites, wooded areas, parked vehicles, and other locations not meant for human habitation.

• Actively seek out, identify, and engage unsheltered individuals throughout Fairfax County's Region 1 locations.
• Build rapport and establish trust with individuals experiencing homelessness in locations not meant for habitation, including campsites, wooded areas, parked cars, hypothermia shelters, and drop-in centers.
• Maintain a consistent outreach schedule while remaining flexible to respond to emerging sites and community referrals.
• Respond to community requests regarding unsheltered individuals.
• Work collaboratively with the multidisciplinary Homeless Healthcare Program (HHP) team to connect individuals to a medical home.

• Utilize agency vehicles to transport unsheltered individuals to medical and dental appointments.
• Coordinate closely with the Fairfax County Health Department Nurse Practitioner to facilitate medical assessments, follow-up care, and referrals.
• Document all transportation and medical coordination services in accordance with agency and contractual requirements.
• Build rapport with medically vulnerable clients who may be disconnected from traditional services.

• Conduct comprehensive assessments.
• Complete bi-weekly dental services by signing up participants, maintaining the schedule, and transporting participants.
• Coordinate transportation for medical appointments when appropriate.
• Utilize a strength-based, person-centered approach to develop individualized service and health plans with clear goals and measurable action steps.
• Provide crisis intervention, safety planning, and stabilization services as needed.
• Conduct health workshops for those who are experiencing homelessness.

• Actively assist individuals in accessing showers, laundry, food, medical care, behavioral health services, substance use treatment, employment services, training, and other critical supports.
• Maintain consistent communication between participants, referral sources, healthcare providers, and community partners.
• Ensure integrated care management through collaboration with Fairfax County Office to Prevent and End Homelessness (OPEH).
• Ensure integrated care management through collaboration with Fairfax County Health Department.
• Ensure integrated care management through collaboration with Community Services Board (CSB).
• Ensure integrated care management through collaboration with PATH (Projects for Assistance in Transition from Homelessness).
• Ensure integrated care management through collaboration with Department of Family Services (DFS).
• Ensure integrated care management through collaboration with Department of Adult and Aging Services.
• Participate in multidisciplinary team meetings, case conferencing, and community-wide trainings.

• Maintain complete, accurate, and timely documentation of services, referrals, transportation, and case notes.
• Enter and update data in the Homeless…