Medical Outreach Case Manager

Title:   Medical Outreach Case Manager 

Department:  Kennedy Emergency Shelter 

Reports to:   Assistant Director of Programs  

Salary:              $52K-$56K 

FLSA Status:    Exempt 

About Us: 

Shelter House was established in 1981 as a grassroots responder to the homelessness crisis in Fairfax County.  Since the organization’s inception, we have adapted and grown to meet community needs, all while working in partnership with government and private partners and community members. Today, Shelter House is a successful and reputable organization of over 100 employees committed to preventing and ending homelessness and domestic violence.  In the last year, our compassionate team of individuals changed the lives of nearly 2,000 individuals, half of which were children. Our Culture is built from our Core Values of Inclusivity, Collaboration, Accountability, Respect, and Empowerment (iC.A.R.E.) 

About the Role: 

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.  

How you will contribute: 

Duties and Responsibilities:   

Street Outreach & Engagement 

• 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. 

Medical Outreach & Transportation 

• 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. 

Case Management & health Stabilization 

• 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 homeless  

Service Coordination & Advocacy 

• 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) 

• Fairfax County Health Department 

• Community Services Board (CSB) 

• PATH (Projects for Assistance in Transition from Homelessness) 

• Department of Family Services (DFS) 

• Department of