Senior Social Worker - Community Care

Veterans Health Administration • Washington, DC

3d • Hybrid

About The Position

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. This role involves providing comprehensive psychosocial assessment, triage, and case management services to Veterans referred to Specialty Care through Community Care. The Social Worker will coordinate with Veterans, ensuring they connect with needed services for treatment, care, admission, discharge planning, and assessing Veteran and caregiver needs via telephone assessments. They will act as a liaison, ensuring Community Care Veterans can connect with required services through the local VAMC. A caseload of high-risk Veterans will be managed, providing case management and enhanced care. The position requires knowledge and experience in medical and mental health diagnoses, disabilities, and treatment procedures, along with the skill to establish and maintain therapeutic relationships with Veterans and caregivers. The Social Worker will independently work with Veterans and their families facing complex medical, psychiatric, emotional, behavioral, and psychosocial problems, conducting thorough initial assessments. Active participation in a multidisciplinary team, collaboration with healthcare professionals, and providing support and care coordination with Community Care clinical teams are essential. Consultation to other treatment teams and staff regarding psychosocial needs and their impact on healthcare planning, treatment compliance, discharge planning, and adjustment is also a key responsibility. The role involves serving as a subject matter expert on complex mental health community care consults, collaborating with VA specialty services and community providers. Knowledge of Veteran's benefits, community resources, and referral processes is required. Case management services will be provided throughout the continuum of care, with a focus on Veterans requiring continued management due to limited supports. The Social Worker will plan, coordinate, monitor, and evaluate the delivery of services within the Community Care program, focusing on efficiency, effectiveness, timeliness, and quality. Continuous improvement of services, identification of areas for improvement, data gathering and analysis, and implementation of improvement ideas are expected. The role includes preparing annual goals and reporting on outcomes, developing systematic plans for reviewing program effectiveness, and maintaining a standardized process for reviewing claims and authorizations. Communication with relevant staff in other services/programs serving the same client group is crucial, as is providing timely and accurate information verbally and in writing. The incumbent will keep the Community Care Chief informed of problems and solutions, write program-specific guidelines and policies, and keep staff informed of eligibility criteria and service changes. Identifying and taking corrective action on service delivery problems with supervisor concurrence is also part of the role. Record maintenance on assigned cases/consults, including data from VISN or VACO, is required. Maintaining a calendar for annual reviews, coordinating and scheduling them, and completing final reports are necessary. Participation in regular meetings with VISN, Optum, Social Work, DOD, Community Care, and other VA specialty services is expected, as is participation in program development and other special duties assigned by the Community Care Chief.

Requirements

• Must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical evaluation.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.
• As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
• 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).
• 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.
• You must be licensed or certified by a state to independently practice social work at the master's degree level.
• You must be licensed or certified by a state at the advanced practice level which included an advanced generalist or clinical examination, unless they are grandfathered by the state in which they are licensed to practice at the advanced practice level (except for licenses issued in California, which administers its own clinical examination for advanced practice) and must be able to provide supervision for licensure.
• You must possess at least two years of experience post advanced practice clinical licensure and should be in a specialized area of social work practice of which, one year must be equivalent to the GS-11 grade level.
• Examples of specialized experience include, but are not limited to: assessing and documenting identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence; use of clinical social work skills; maintaining patient privacy and confidentiality per policies, handbooks or directives; acting as an advocate with appropriate community service providers and agencies when it serves the best interest of the patient and family members/caregiver; independently assessing the psychosocial functioning and needs of patients and their family members, identifying the patient's strengths, weaknesses, coping skills, and psychosocial acuity.
• Applicable experience must demonstrate possession of advanced practice skills and judgment.
• Skill in a range of specialized interventions and treatment modalities used in specialty treatment programs or with special patient populations. This includes individual, group, and/or family counseling or psychotherapy and advanced level psychosocial and/or case management.
• Ability to incorporate complex multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice.
• Knowledge in developing and implementing methods for measuring effectiveness of social work practice and services in the specialty area, utilizing outcome evaluations to improve treatment services and to design system changes.
• Ability to provide specialized consultation to colleagues and students on the psychosocial treatment of patients in the service delivery area, as well as role modeling effective social work practice skills.
• Ability to expand clinical knowledge in the social work profession, and to write policies, procedures, and/or practice guidelines pertaining to the service delivery area.
• As determined by VA Handbook 5019.
• In addition this position may require prolonged sitting, standing, walking, rounding with team, charting, light lifting, pulling, and pushing.

Nice To Haves

• Community Care experience.
• Experience working with care coordination for patients with complex medical co-morbidities, especially as they transition from inpatient care to the next level of care which may include acute inpatient rehabilitation or Long-Term Acute Care.

Responsibilities

• 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.
• 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 healthcare 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.
• 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.
• 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.

Benefits

• A career with the U.S. government provides employees with a comprehensive benefits package.
• As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding.
• Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent.
• Contact the hiring agency for more information on the specific benefits offered.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior