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

Veterans Health Administration • Miami, FL

2d

About The Position

The Social Worker (Program Coordinator) in the Care Coordination and Integrated Case Management (CC&ICM) program coordinates, implements, and maintains the program across a VA Health Care System. The position combines direct clinical services with program management to improve outcomes for Veterans with complex medical, behavioral health, and psychosocial needs. The Senior Social Worker leads and manages integrated care processes that connect multiple services to support seamless, patient-centered outcomes, combining administrative leadership, clinical oversight, and interdisciplinary collaboration.

The incumbent manages daily program operations, develops operating policies and procedures, and prepares statistical reports for facility, VISN, and national use. The role supports interprofessional collaboration across the continuum of care and provides outreach and education to interdisciplinary teams about integrated case management. It also involves identifying Veterans at high risk or with high resource utilization, facilitating care coordination and coordinated care review meetings, ensuring assignment of an appropriate lead coordinator, and developing and monitoring program outcomes.

The position requires advanced knowledge of the biopsychosocial, behavioral health, and mental health needs of Veterans and their family members or caregivers. The Social Worker provides specialized interventions and treatment modalities, including individual, group, and/or family counseling or psychotherapy and advanced psychosocial or case management services. The role incorporates multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice, measures the effectiveness of social work services, uses outcome evaluations to improve treatment, and designs system changes. Regular travel to other locations of care within the NF/SGVHS is required. The stated schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m.; supervisors may approve different shifts temporarily or permanently based on facility or patient-care needs.

Requirements

• U.S. citizenship, subject to the stated VA policy exception for non-citizens when qualified citizens cannot be recruited.
• Proficiency in written and spoken English.
• Master’s degree in social work from a school fully accredited by the Council on Social Work Education (CSWE); a doctoral degree cannot substitute for the master’s degree.
• State licensure or certification to independently practice social work at the master’s degree level.
• For the GS-12 Senior Social Worker grade: at least two years of experience after advanced practice clinical licensure, including one year equivalent to the GS-11 grade level.
• Advanced practice-level state license or certification, including an advanced generalist or clinical examination, subject to the stated grandfathering provisions.
• Ability to provide supervision for licensure; advanced license must be submitted with the application.
• Skills in specialized interventions and treatment modalities, including individual, group, and/or family counseling or psychotherapy and advanced psychosocial or case management.
• Ability to incorporate complex multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice.
• Knowledge of methods for measuring the effectiveness of social work practice and services and using outcomes to improve treatment and design system changes.
• Ability to provide specialized consultation to colleagues and students and role model effective social work practice.
• Ability to expand clinical knowledge and write policies, procedures, or practice guidelines for the service delivery area.
• Must meet the physical demands of the position, with reasonable accommodations as applicable; good manual dexterity, ability to communicate verbally and in writing, ability to read computer-screen information, and ability to sit for long periods.
• Must complete required pre-employment screening and onboarding, including a background/security investigation, pre-employment physical evaluation, and seasonal influenza vaccination requirements; applicants in testing-designated positions are subject to urinalysis.
• Males born after December 31, 1959 must meet Selective Service registration requirements.
• Must serve a one- or two-year trial period, subject to written certification for continued employment.

Nice To Haves

• Certification or post-master’s training from a nationally recognized professional organization or university in a specialty area, including a defined curriculum or course of study and internship or equivalent supervised professional experience.
• CME reimbursement may be available for full-time employees with board certification.

Responsibilities

• Coordinate, implement, and maintain the Care Coordination and Integrated Case Management program across a VA Health Care System.
• Lead, coordinate, and manage integrated care processes connecting multiple services to support patient-centered outcomes.
• Manage daily program operations and develop policies and procedures for program operation.
• Prepare statistical reports for facility, VISN, and national use.
• Support interprofessional collaboration and establish structure and standards across the continuum of care.
• Provide outreach and education to interdisciplinary teams on the benefits and strategies of integrated case management.
• Identify Veterans who are high risk or high utilizers of resources and provide or facilitate care coordination.
• Facilitate coordinated care review team meetings and ensure assignment of an appropriate lead coordinator.
• Develop and monitor program outcomes.
• Provide specialized individual, group, and/or family counseling or psychotherapy and advanced psychosocial or case management interventions.
• Incorporate multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice.
• Develop and implement methods to measure the effectiveness of social work practice and services, using outcome evaluations to improve treatment and design system changes.
• Provide specialized consultation to colleagues and students on psychosocial treatment and model effective social work practice skills.
• Expand clinical knowledge and write policies, procedures, and/or practice guidelines for the service delivery area.
• Travel regularly to other locations of care within the NF/SGVHS to perform job duties.

Benefits

• Competitive salary, annual performance bonus, and regular salary increases.
• 50–55 days of paid time off per year, including annual leave, sick leave, federal holidays, and possible paid CME absence.
• Traditional federal pension, with five-year vesting, and federal 401(k) with up to 5% in VA contributions.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement.
• Possible $1,000 per year CME reimbursement for full-time employees with board certification.
• Free liability protection with tail coverage.
• Potential credit toward annual leave accrual based on prior work or military service, subject to approval.

What This Job Offers

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