Senior Social Worker - Community Care

Summary

The Senior Social Worker serving as the Community Care Social Worker works closely with staff in all areas of the hospital and is administratively responsible for ensuring appropriate coordination for eligible veterans who require community care.

Duties

Major duties include, but are not limited to: Provides comprehensive psychosocial assessment, triage and case management services to Veterans currently referred to Specialty Care through Community Care. Coordinate with Veterans referred to Community Care, coordinating needed services for treatment, care, admission, discharge planning, and assessing Veteran and caregiver needs via telephone assessments. Provide clinical assessment and act as a liaison ensuring Community Care Veterans are able to connect with required services through the local VAMC if appropriate or desired. Maintain a caseload of high-risk Veterans, providing case management and enhanced care. Knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures. Skill and expertise to establish and maintain effective therapeutic relationships with Veterans and caregivers assigned to specialty care through Community Care. Independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral and psychosocial problems. Complete thorough initial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. Actively participate as a member of a multidisciplinary team by collaborating with other healthcare professionals. Provide support and care coordination working with Community Care clinical teams. Provide consultation to other treatment team and staff members as well as sponsors/vendors regarding psychosocial needs of Veterans and/or their families and the impact of the identified psychosocial problems on the Veteran's health care planning, compliance with treatment, discharge planning and ongoing adjustment following Community Care specialty clinic treatment. Serve as a subject matter expert on complex mental health community care consults such as Residential Rehab Treatment Program and/or Intensive Outpatient Program consults, collaborating with VA specialty services and community providers to facilitate. Knowledge of Veteran's benefits and services, community resources and process for making appropriate referrals to community and other governmental programs or agencies. Provide case management services to Veterans and their families throughout the continuum of care. Provides support, assessment, and appropriate interventions (case management) for Veterans that require continued case management due to limited supports and resources. Plan, coordinate, monitor, and evaluate the delivery of services within the Community Care program. Monitors the efficiency, effectiveness, timeliness, and quality of services offered within this program. Responsible for continuously improving the efficiency, effectiveness (in terms of cost and program interventions) and the quality of services. Identifies areas for improvement, gather relevant data, assess the data, develop and implement ideas for improvement, and evaluate efficacy of improvements. Prepares the goals for each new fiscal year and reports on outcome at the end of the fiscal year. Developing a systematic plan for reviewing and appraising the effectiveness of the Community Care programs in accordance with VA, VISN, VACO and local facility policy and procedures. Develops and maintains a standardized process for reviewing questions regarding claims and authorizations. Develops and maintains communication with relevant line and supervisory staff in other services/programs that serve the same group of clients. Provides timely and accurate information both verbally and written for reports to their supervisor, Chief of Community Care, and others as indicated in the program requirements. The incumbent keeps the Community Care Chief apprised of problems and recommended solutions to problems encountered in the incumbent's area of responsibility. Writes program specific guidelines and policies as required and sees that these policies are implemented. Keeps staff fully informed of eligibility criteria, relevant services, and changes as they occur within their program. Identifies problems in service delivery within their assigned program and takes corrective action with the concurrence of their supervisor. Maintain records on assigned cases/consults. These files will also include data from VISN or VACO when appropriate. Maintains a calendar of when annual reviews are due and coordinates and schedules reviews and completes final report. Participate in regular meetings with the VISN, Optum, Social Work, DOD, Community Care, and other VA specialty services. Participate in program development and other special duties and projects as assigned by the Community Care Chief or designee. Work Schedule: Monday - Friday; 8:00am - 4:30pm Telework: Available. AD-HOC only Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. You must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Education and/or Experience Combination. You must possess a master's degree in Social Work from a school of social work fully accredited by the Council on Social Work Education (CSWE). Graduates of schools of social work that are in candidacy status do not meet this requirement until the school of social work is fully accredited. Note: A doctoral degree in Social Work may NOT be substituted for the master's degree in Social Work. License or Certification. You must be licensed or certified by a state to independently practice social work at the master's degree level. Grandfather Provision. A Social Worker employed in VHA on the effective date of the qualification standard (9/10/2019) who did not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed, the following provisions apply: Employees may be reassigned, promoted up to and including the full performance (journey) level or changed to lower grade within the occupation but may not be promoted beyond the journeyman level or placed in supervisory or managerial positions. Employees in an occupation that requires a licensure/certification/ registration only at higher grade levels must meet the licensure/ certification/registration requirement before they can be promoted to those higher grade levels. Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended or be reappointed on a temporary or permanent basis until they fully meet the basic requirements of the standard. Employees who are converted to title 38 hybrid status under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of re-entry to the occupation. Employees initially grandfathered into this occupation who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard