Social Worker - Transition Care Management

This position is located at the Fredericksburg, VA Community-Based Outpatient Clinic (CBOC). The primary responsibility of the position is to ensure the transition of care of Veterans and Active Duty Servicemembers, from the DoD Military Treatment Facilities (MTF) and Warrior Transition Units (WTU) to the Veterans Health Administration (VHA) is safe and continuous. The TCM SW Case Manager supports the Veteran, the Veteran's family, and the Veteran's Caregiver's and coordinates health needs across agencies, sites and unique episodes of care in order to optimize service delivery, improve quality of care, and enhance both patient experiences and outcomes. The TCM case manager performs clinical interventions and case management services, in collaboration with the other members of the TCM Program, and with guidance from the Interdisciplinary Care Management Review Team (IDCMRT) in order to meet the biological, psychological, and environmental needs of SM/Vs through a well-developed Inter-Agency Comprehensive Plan (ICP) Checklist. When determined by the IDCMRT, the TCM may serve as the Lead Coordinator for assigned patient. Duties include, but not limited to: Exhibits a high level of skill and expertise in the work with patients and families who are experiencing a wide range of complicated mental, emotional, behavioral, physical, psychosocial, and environmental problems. Possesses knowledge of medical and mental health diagnoses (included but not limited to amputation, burns, vision loss, TBI, PTSD, and the Adjustment/Anxiety/Mood disorders) as well as insight into the needs of and services required for individuals with these conditions and the skills to implement treatment modalities. Complete a comprehensive assessment of the veteran in collaboration with the veteran, family members and significant others to identify needs and formulate a plan to meet those needs. Evaluates the need for mental health services and makes appropriate referrals for individual, group, marital and family treatment services. Must be sensitive to the ethnic and cultural diversity and age-specific challenges of the Post 9/11 population and adjusts intervention and treatment plans as appropriate. As a member of the health care team, participates fully in developing, planning, implementing and evaluating the ICP Checklist, including periodic updates and uploading patients' established case management contact plans into the Care Management Tracking Referral Application (CMTRA). Coordinates care with interdisciplinary team to promote continuity for Post 9/11 SM/Vs and their families. Researches, develops maintains and uses appropriate community resources. Serves as an advocate for Post 9/11 SM/Vs and their families, helping them access needed services at the facility, at other VA facilities, and in the community. Assists Post 9/11 SM/Vs and their families with advance directives, guardianships, and applications for home care and extended care services. Participate in an On-Call Rotation Schedule to accommodate patient care needs during the weekend. Performs other duties as assigned. Work Schedule: 08:00am to 4:30pm Fair Labor Standards Act (FLSA) Status: Non-Exempt Recruitment/relocation incentives: Not authorized Permanent Change of Station (PCS): Not authorized Appraised Value Offer (AVO): Not authorized Financial Disclosure Report: Not required This position is NOT eligible for the Education Debt Reduction Program (EDRP) To qualify for this position, applicants must meet all requirements by the closing date of this announcement, . Basic Requirements: The basic requirements for employment as a VHA social worker are prescribed by statute in 38 U.S.C. 7402(b)(9), as amended by section 205 of Public Law 106-419, enacted November 1, 2000. To qualify for appointment as a social worker in VHA, all applicants must meet the following: Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. 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). 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. A doctoral degree in social work may not be substituted for the master's degree in social work. 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. For the GS-11 grade level and above, the candidate must be licensed or certified. At the time of appointment, the supervisor, chief social work or social work executive will provide the unlicensed/uncertified social worker with the written requirements for licensure or certification, including the time by which the license or certification must be obtained and the consequences for not becoming licensed or certified by the deadline. Failure to Obtain License or Certification: In all cases, social workers must actively pursue meeting state prerequisites for licensure or certification starting from the date of their appointment. Failure to become licensed or certified within the prescribed amount of time will result in removal from the GS-0185 social worker series and may result in termination of employment. Loss of Licensure or Certification: Once licensed or certified, social workers must maintain a full, valid and unrestricted independent license or certification to remain qualified for employment. Loss of licensure or certification will result in removal from the GS-185 social work series and may result in termination of employment. Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. GS-11 Social Worker Experience and Licensure: Appointment to the GS-11 grade level requires completion of a minimum of one (1) year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non- VA experience) and licensure or certification in a state at the independent practice level. OR Education: In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required one year of professional social work experience in a clinical setting. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, candidates must demonstrate all of the following KSAs: Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, cultural, ethnic, educational and other diversified backgrounds. Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e. acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan. Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals. Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment. References: VA Handbook 5005/120, Part II, Appendix G39; dated September 10, 2019 The full performance level of this vacancy is GS-11. The actual grade at which an applicant may be selected for this vacancy is GS-11. Physical Requirements: The work is primarily non-strenuous though a significant amount of walking is required for face to face contact with patients, family members and medical staff. Ability to life 5- 10 pounds, mostly documents and/or binders is required. The ability to sit for 1-2 hours and do substantial computer work.
  • Department: 0185 Social Work
  • Salary Range: $64,009 to $83,210 per year

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