Senior Social Worker - Community Care Network, Skilled Nursing Facility Rehab Program

Full Job Description

This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program.

You must meet specific eligibility requirements per VHA policy and submit your EDRP application within four months of appointment.

Program Approval, award amount (up to $200,000) & eligibility period are determined by the VHA Education Loan Repayment Services program office after review of the EDRP application.

Former EDRP participants ineligible to apply. BASIC REQUIREMENTS United States Citizenship. Must be a Citizen of the United States. English Language Proficiency.

Candidates must be proficient in spoken and written. English to be appointed as authorized by 38 U.S.C. § 7403(f). 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.

Verification of the degree can be made by going tohttp://www.cswe.org/Accreditation to verify that the social work degree meets the accreditation standards for a masters of social work. Licensure.

Persons hired or reassigned to social worker positions in the GS-0185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level.

Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/ Grandfathering Provision.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

GRADE DETERMINATION Senior Social Worker, GS-12 Experience and Education.

The candidate must have at least two years of experience post advanced practice clinical licensure and should be in a specialized area of social work practice of which, one year must be equivalent to the GS-11 grade level.

Senior social workers have experience that demonstrates possession of advanced practice skills and judgment. Senior social workers are experts in their specialized area of practice.

Senior social workers may have certification or other post-masters 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 a specialty.

Licensure/Certification.

Senior social workers must be licensed or certified by a state at the advanced practice level which included an advanced generalist or clinical examination, unless they are grandfathered by the state in which they are licensed to practice at the advanced practice level (except for licenses issued in California, which administers its own clinical examination for advanced practice) and they must be able to provide supervision for licensure.

Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, candidates must demonstrate all of the following KSAs: Skill in a range of specialized interventions and treatment modalities used in specialty treatment programs or with special patient populations.

This includes individual, group, and/or family counseling or psychotherapy and advanced level psychosocial and/or case management.

Ability to incorporate complex multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice.

Knowledge in developing and implementing methods for measuring effectiveness of social work practice and services in the specialty area, utilizing outcome evaluations to improve treatment services and to design system changes.

Ability to provide specialized consultation to colleagues and students on the psychosocial treatment of patients in the service delivery area, as well as role modeling effective social work practice skills.

Ability to expand clinical knowledge in the social work profession, and to write policies, procedures, and/or practice guidelines pertaining to the service delivery area.

Preferred Experience Experience with performing assessments, treatment planning, discharge planning, and care coordination.

Experience with Geriatrics & Extended Care programs and services provided in the community to assist Veterans with aging in place, such as: Homemaker/Home Health Aide, Home Respite, Community Adult Day Health Care and Veteran Directed Care programs.

Reference. For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements.

Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position.

Position requires walking throughout the clinic and/or Medical Center, standing for extended periods of time, and involves sitting at a computer and in counsel and consultation with Veterans and interdisciplinary teams.

Work is performed in a wide range of settings, including office/clinic setting with minimal risks that require normal safety precautions; the area is adequately lighted, heated, and ventilated.

The position requires the ability to handle multiple tasks in sometimes stressful situations while engaging in counsel and consultation with Veterans and interdisciplinary teams. Major Duties:

The incumbent is the Senior Social Worker of the Community Care Network - Skilled Nursing Facility (CCN-SNF) Rehab Program for the Orlando VA Health Care System.

The incumbent is delegated the responsibility and authority for the planning and coordination of all elements which constitute the CCN SNF in collaboration with the Nurse Coordinator partners in the Community Care Department.

Duties and functions of the Senior Social Worker, (CCN-SNF) Rehab Program include but are not limited to the following: The incumbent independently reviews the referrals received from community hospitals and other settings and assesses the referrals for administrative and clinical eligibility based on VA guidelines.

The incumbent acts as liaison between VA and the community SNFs actively participating with Optum in CCN for admission purposes.

The incumbent is responsible for identifying Veterans that will need transitional care prior to discharge home.

The incumbent is responsible for overseeing the placement of Veterans into the community SNFs in Optum CCN under VA authorization and assuring that placements meet VA eligibility requirements.

The incumbent responsible for independently entering documentation in accordance with medical center policy, ensuring it is completed after each encounter in the Veteran's electronic medical record utilizing the approved program, e.g., CPRS, Consult Toolbox, VistA, HealthShare Referral Manager, Cerner, etc.

The incumbent documents independently in the medical records utilizing paper and/or electronic formats, including psychosocial assessments, diagnostics, treatment, progress notes, follow up, and referral.

Documentation includes but is not limited to initial evaluations, suicide risk assessments, group notes, care coordination, case management, advanced directives, clinical reminders or initial treatment plans.

Highly developed professional, clinical and advanced practice skills are routinely used to assist Veterans with complex problems.

The incumbent is responsible for processing orders and authorizations for eligible Veteran placements in accordance with Integrated Veteran Care Field Guidebook guidelines.

Verification of the community provider's active status will be confirmed in the Provider Portal Management System (PPMS) maintained by Office of Integrated Veteran Care (IVC) prior to authorization.

The incumbent works independently in providing appropriate documentation, review and follow-up of complaints within the CCN SNF Rehab Program.

The incumbent provides case management as needed utilizing knowledge of various insurance types (e.g., Medicare, Medicaid, other private health insurances, and VA benefits) to recommend appropriate referrals and discharge plans to community providers.

This may include verification of Veteran status and eligibility for participation in VA programs, monitoring admission and discharge dates of participants, reviewing and completing referrals, collecting and submitting Veteran information.

The incumbent must be proficient in VA Programs relevant to discharge planning and be knowledgeable of referral processes, eligibility criteria and clinical requirements.

Provides both informal and formal education to VA staff, as well as community SNF staff, on any changes in VA policy concerning their specific programs, referral procedures and documentation requirements.

The incumbent independently coordinates care including serving as an advocate on behalf of the Veterans admitted to non-VA hospitals, SNFs, or other Vas out of area to ensure comprehensive service delivery and linking and referring Veterans to the VA Healthcare System or community provider.

The incumbent engages in coordination with community agencies, organizations, and groups to learn of services or resources available for Veterans with complex needs as well as provides current information on services and benefits available.

The incumbent performs accountability functions by documenting all contacts with patients/families in the medical charts and completing other reports in accordance with Orlando VA Healthcare System and respective professional discipline service policies.

The incumbent works with Orlando VA Healthcare System multi-disciplinary teams and community agencies to strive to develop more effective and efficient ways of delivering healthcare services.

Work Schedule: Monday - Friday; 8:00am - 4:30pm Telework: Ad-hoc - Based on Service needs Virtual: This is not a virtual position.

Functional Statement #: 82672F EDRP Authorized: Approved for Education Debt Repayment Program: Learn more (Former EDRP participants ineligible to apply for incentive.)