The Social Worker - Transition and Care Management (Program Coordinator) oversees all transition activities and the coordination of care and services for Transition and Care Management (TCM) service members and Veterans treated at the facility.
Service members and Veterans come from a wide geographic area. Their health care and psychosocial problems and needs are complex and require a high degree of clinical oversight and creative problem solving. The incumbent facilitates efficient and appropriate delivery of services across episodes of care within the Medical Center and Community-based Outpatient Clinics (CBOC), including Mental Health Services. The incumbent plans, develops, implements, and evaluates the facility Transition and Care Management Program to ensure continual quality improvement and excellence in customer service. The work affects a wide range of agency activities and operations. It directly affects the health and well-being of the patients served and relationships with community organizations and stakeholders.
The Program Manager has programmatic responsibility and may have administrative responsibility for facility staff providing services to TCM service members and Veterans, including social worker case managers and Transition Patient Advocates. The Transition and Care Management Program Manager is assigned to a Department of Veterans Affairs (VA) medical center. The incumbent is a master's prepared social worker.
Work involves oversight of a complex array of services, both clinical and administrative, for all TCM service members and Veterans treated by the facility. Work requires the exercise of mature professional judgment and flexible use of administrative, leadership, and social work skills. The population served has unique needs, and the re-adjustment to civilian life, mental health issues, and the necessary involvement of family and other agencies often result in serious and complicated cases. Patients present with a wide range of psychosocial and environmental problems that require creative problem solving and planning. Decisions concerning planning, organizing, and implementing the plans are often complicated by the various agencies and individuals involved in the care plan.
The Social Worker is capable of practicing at the advanced level and has specialized knowledge of practice typically related to a particular diagnosis or population. Incumbent should have at least 2 years in an area of specialized social work practice and licensed or hold certification in a state at the advanced practice level.
Develops and maintains a system to identify TCM patients served by the facility and those in the catchment area not currently seen. This may involve use of a TCM Registry, Patient Treatment File searches, the Care Management Tracking and Reporting Application (CMTRA), Veterans Health Information System and Technology Architecture (VistA) and Computerized Patient Record System (CPRS) records, Northeast Program Evaluation Center (NEPEC) data reports and/or Classification reports, Patient Data Exchange, Network Health Exchange, contacts with the Veterans Integrated Service Network (VISN) and VA Central Office, and contacts in the community.
Serves as the facility point of contact for all inquiries regarding seamless transition of TCM Veterans and as point of contact for TCM service members and Veterans seeking health care from the facility. These duties include a wide variety of stakeholders (e.g., Veterans, families, state and community agencies, Veterans Service Organizations (VSOs), military support programs, etc.). Incumbent addresses Congressional inquiries and VISN and VA Central Office action items as requested.
Oversees or works closely with facility care management teams to include but, not limited to nurse and social worker case managers, the Visual Impairment Services Team (VIST) Coordinator, the Spinal Cord Injury (SCI) Coordinator and the Women Veterans Program Manager.
Ensures TCM Veterans receive comprehensive preventive mental and physical health evaluations.
Promotes and coordinates evaluations for the Transition and Care Management program for the Medical Center and any outlying CBOCs.
Prepares program reports for VA Central Office, the VISN Point of Contact (POC), and Medical Center leadership.
Develops procedures for referrals between the VA medical center, Military Treatment Facilities and/or community hospitals that promote appropriate and timely inter-facility transfers.
Researches community resources (local, state, and national) that are available to provide continuity of care and to enhance the quality of life of the Veteran. Incumbent disseminates information on resources to other Transition and Care Management Program Managers within the VISN.
Is responsible for monitoring Veterans Health Administration (VHA) performance monitors and measures related to TCM to assure they are met or exceeded.
Full list of duties avaialabe upon request from the HR Specialist listed as the POC.
Work Schedule: Monday - Friday: 8:00 AM - 4:30 PM
Financial Disclosure Report: Not required
Conditions of Employment
You must be a U.S. Citizen to apply for this jobDesignated and/or random drug testing may be requiredSelective Service Registration is required for males born after 12/31/1959You may be required to serve a probationary periodSubject to a background/security investigationMust be proficient in written and spoken EnglishSelected applicants will be required to complete an online onboarding process
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 07/06/2020.
1. United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
2. Education: Have a master's degree in social work from a school of social work fully accredited by the Council on Social Work Education (CSWE). A doctoral degree in social work may not be substituted for the master's degree in social work.
3. Licensure. Persons hired or reassigned to social worker positions in the GS-185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level.
Preferred Experience: The Social Worker Program Coordinator should have at least two years in an area of specialized social work practice and must be independently licensed or certified by a state to practice at the advanced practice level.
Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.
For GS-12 Social Worker Program Manager:For Social Worker Program Coordinators, grades are determined by the scope of responsibility and the type, size, and complexity of the assignment.
(a) Experience, Education and Licensure. Individuals assigned as social worker program coordinator or manager must be licensed or certified at the advanced practice level. Their experience must demonstrate possession of advanced practice skills and judgment, demonstrating progressively more professional competency. They may have certification or other post-master's degree training from a nationally recognized professional organization or university that includes a defined curriculum/course of study and internship, or equivalent supervised professional experience. In addition, the candidate must demonstrate the professional KSAs in subparagraph (b) below.
(b) Demonstrated Knowledge, Skills, and Abilities
1. In-depth knowledge of the program coordinated, and demonstrated knowledge and ability to write policies, procedures, and/or practice guidelines for the program.
2. Knowledge and skill in management/administration, which includes supervision, consultation, negotiation, and monitoring.
3. Ability to supervise multidisciplinary staff assigned to the program.
4. Ability to organize work, set priorities, meet multiple deadlines, and evaluate assigned program area(s).
5. Ability to provide training, orientation, consultation and guidance within clinical specialization of practice.
Assignments: The KSAs shown above apply to all Social Worker Program Coordinator grade levels.
1. GS-12 Social Worker Program Coordinators. Program coordinators at the GS-12 grade are administratively responsible for a clinical program providing treatment to patients in a major specialty, such as Spinal Cord Injury (SCI) coordinators, Visual Impairment Services Team (VIST) coordinators, Homeless Veterans Program (HVP) coordinators, Community Nursing Home Program (CNHP) coordinators. They may be the sole practitioner in this specialty at the facility and typically provide direct patient care services in the program area. They manage the daily operation of the program, develop policies and procedures for program operation, and prepare reports and statistics for facility, VISN, and national use. They may be responsible for the program's budget.
Reference: VA HANDBOOK 5005/23 Part II Appendix G39
The incumbent appropriate use of equipment, supplies.
The incumbent maintains safe, orderly work areas.
The incumbent reports any accident to self, patient, and staff and fills out appropriate forms.
The incumbent follows Life Safety Management (fire protection) procedures.
The incumbent reports safety hazards, accidents and injuries and reviews hazardous.
The incumbent follows Emergency Preparedness plan, follows security policies/procedures, and complies with federal, state and local environmental and other requirements preventing pollution, minimizing waste, and conserving cultural and natural resources.
The incumbent demonstrates infection control practices for disease prevention (i.e. hand washing, universal precautions/isolation procedures, including TB requirement/precautions).
The physical demands of this position involve primarily walking, talking, driving, use of the telephone, etc. Strenuous physical activity is not required although the incumbent is expected to withstand pressure and stress as part of their day-today activities.
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.