Social Worker (Program Coordinator) - Care Coordination and Integrated Case Management Program

Department of Veterans Affairs•Fargo, ND

40d•Onsite

About The Position

The Fargo VA Health Care System is recruiting for 1 full-time Social Worker (Program Coordinator). The position will be responsible for coordinating, implementing, and maintaining the Care Coordination and Integrated Case Management Program (CC&ICM) Program across the Fargo HCS. VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU This position is essential to ensuring case management is coordinated for our most complex Veterans. The focus is on Veterans in the emergency room and Veterans who are receiving care in the community. The coordinator facilitates weekly meetings to staff cases and determine case management, provide training for case managers in Fargo and CBOCs, collect and maintain data for the program and ensure program implementation continues to meet goals of providing better coordination of care for Veterans and keeping Veterans in VA system.

Responsibilities

Subject Expert - The position will be a subject expert for the CC&ICM program. The position will be a champion for the implementation and maintenance of the CC&ICM program.
Groups - The position may complete groups for CC&ICM. The position will demonstrate an understanding of group facilitation, development, and recruitment. When appropriate the position will utilize telehealth for groups.
Coordination - The position will coordinate CC&ICM development and implementation at the facility and/or CBOC's. The position will provide facility education to staff. Veteran recruitment for CC&ICM. The position will provide training regarding CC&ICM across the entire HCS. This position will also be the lead on implementing the CC&ICM.
Psychosocial Assessment - The social worker will develop an assessment of the veteran, family, economic, community, and psychosocial support systems when clinically indicated. The assessments must reflect a high level of skill in gathering, analyzing, interpreting, and documenting data that is pertinent and directly related to patient health care planning, treatment, education and case management. The veteran, family members, significant others and the interdisciplinary treatment team are involved in this process, whenever possible. The goal of the communication is to highlight the veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the veteran's functional status and safely maintain the veteran in his/her home.
Clinical diagnosing using DSM-5 and ICD-10 behavior codes - Incumbent demonstrates knowledge in DSM-5 diagnosing and documents diagnostic impressions in psychosocial assessments when appropriate. Clinician may function independently or within a team to determine an appropriate diagnosis and formulate a treatment plan based on that diagnosis.
Treatment Planning/Goal Setting - Incumbent demonstrates basic knowledge of psychosocial treatment modalities and demonstrates the ability to implement treatment modalities in working with individuals, families, and groups to achieve treatment goals. This requires judgment and skill in utilizing supportive, problem solving, or crisis intervention techniques. The social worker is responsible for developing a treatment plan, and setting achievable treatment goals with the veteran/family in collaboration with the primary care interdisciplinary treatment team members when indicated. Incumbent demonstrates basic knowledge of medical and mental diagnoses, disabilities, and treatment procedures to include acute, chronic and traumatic illnesses/injuries; common medications and their effects/side/effects; and basic medical terminology.
Therapy - Social worker may provide the veterans and their caregivers with ongoing psychotherapy (group and/or individual) and/or supportive counseling when appropriate. Incumbent is able to demonstrate the ability to utilize the DSM-V to ensure appropriate treatment recommendations.
Referral to service providers - Throughout the course of treatment the social worker is the subject matter expert on VA and/or community resources. The social worker will collaborate with other service providers in reassessing the veteran's needs for VA and community resources and entitlements. The social worker is responsible for educating the veteran and/or caregiver of the available services and assisting them in establishing the appropriate referrals based on the veteran's preference or that of his/her surrogate decision-maker.
Resource Development - The social worker is responsible for developing a resource file of VA and community social service programs and will refer the veteran to needed services.
Advocacy - Social worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the veteran/family.