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.
Major duties include, but are not limited to: 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. Knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures.
Skill and expertise to establish and maintain effective therapeutic relationships with Veterans and caregivers assigned to specialty care through Community 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 health care 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. Knowledge of Veteran's benefits and services, community resources and process for making appropriate referrals to community and other governmental programs or agencies.
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. These files will also include data from VISN or VACO when appropriate.
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. Work Schedule: Monday - Friday; 8:00am - 4:30pm Telework: Available. AD-HOC only.
Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education.
For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.
Elizabeth.Mcneill@va.gov · 910-488-2120 X1636
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $110910 – $144186/yr.
This position is eligible for telework.
Applications close on 2026-10-15.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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