Social Work (Program Coordinator)

U.S. Department of Veterans Affairs; Prescott (AZ); Hybrid; USD 75,000 - 110,000; Full time

Benefits offered by this job

Federal health/vision/dental

Paid time off

Thrift Savings Plan

Job summary

U.S. Department of Veterans Affairs seeks an experienced Social Worker at the advanced level to coordinate care across the PACT and CCICM frameworks. The role includes direct clinical services within an interdisciplinary primary care team and oversight of care coordination standards.

The incumbent supports high-need Veterans, leads program coordination, and ensures integration with facility-wide care teams while utilizing telehealth modalities as required.

Qualifications

• MSW from an accredited program and appropriate licensure.
• Experience in clinical social work with high-need Veterans.
• Ability to lead interdisciplinary teams and coordinate care.

Responsibilities

• Lead CCICM framework implementation with national guidance.
• Provide direct PACT social work services within primary care.
• Collaborate with nursing, specialty care, navigators and leaders.
• Co-chair CCICM and CCRT meetings and monitor quality metrics.
• Use Tele-Social Work and Tele-Mental Health per standards.

Skills

Clinical social work

Care coordination

Interdisciplinary collaboration

Tele-social work

Supervision

Education

MSW or equivalent

Tools

CSSRS

CSRE

Job description

Summary

The incumbent practices at the advanced social work level - providing both program coordination and direct clinical practice. This involves implementing - managing - and evaluating an interdisciplinary care coordination framework aimed at improving outcomes for high-need - high-risk Veterans - as well as provide comprehensive biopsychosocial assessments - intervention - treatment planning - and case management for Veterans receiving primary care through the Patient Aligned Care Team (PACT).

Duties

• VA Careers - Licensed Clinical Social Worker: https://youtube.com/embed/U_xC25QsN0w Total Rewards of a Allied Health Professional The purpose of this position is to strengthen the medical center's ability to provide integrated - patient-centered - and coordinated care for Veterans with complex medical - behavioral health - and psychosocial needs as well as ensure that the Care Coordination and Integrated Case Management (CCICM) framework is implemented consistently - with oversight of policy adherence - training - and monitoring of care coordination standards
• The position will also provide accessible - high-quality PACT social work services - addressing psychosocial barriers that impact health outcomes and reduce duplication of services - enhance communication among clinical programs - and improve care transitions throughout VHA's continuum of care
• The position operates throughout the Veterans Health Administration (VHA) healthcare system - serving Veterans across outpatient and inpatient environments
• Work may occur in PACT - providing direct clinical social work services as part of an interdisciplinary primary care team
• Work may also occur within CCICM Program Infrastructure - collaborating with nursing counterparts - specialty care teams - navigators - case managers - and facility leadership
• This position also works with the Care Coordination Review Team (CCRT) - co-leading interdisciplinary meetings focused on moderate- and high-complexity Veterans and will also utilize virtual modalities including Tele-Social Work and Tele-Mental Health - as required by national VHA standards
• This role requires flexibility in working across multiple clinics and service lines - with duties occurring in offices - primary care settings - specialty clinics - and virtual platforms
• CCICM Program Coordination - 50% -Leads implementation - coordination - and management of the CCICM framework - ensuring alignment with national guidance and accreditation standards through the following: - Collaborates with nursing leadership to develop - monitor - and evaluate CCICM operations - Identifies and monitors high-need Veteran cohorts requiring coordinated - integrated case management - Ensures integration with facility-wide care coordination teams - navigators - and specialty programs for seamless continuity of care - Provides oversight of CCICM education initiatives for staff and Veterans - Co-coordinates CCRT activities and assigns Lead Coordinators - Manages CCICM-related data tracking - reporting - and quality improvement activities PACT Social Work Services - 50% - Provides direct clinical social work services to PACT patients - including assessment - treatment planning - intervention - and follow-up - Participates in daily PACT huddles and interdisciplinary collaboration to support population health efforts - Provides crisis intervention - resource navigation - and solution-focused social work services - Ensures adherence to suicide prevention protocols - including Columbia-Suicide Severity Rating Scale (CSSRS) - Comprehensive Suicide Risk Evaluation (CSRE) - safety planning - and required documentation - Addresses psychosocial barriers impacting access - adherence - and overall health outcomes - Collaborates with medical - nursing - and behavioral health staff to support high-quality - Veteran-centered care This position functions at the GS-12 advanced practice level - requiring specialized experience - advanced licensure - and the ability to provide clinical supervision
• The scope of work includes program coordination - administration - advanced clinical services - interprofessional leadership - and integrated case management
• Work Schedule: Monday through Friday - 8 AM to 4:30 PM Recruitment/Relocation Incentives (Sign-on Bonus): May be authorized for highly qualified candidates Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child
• Child Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: ADHOC- May be available for highly qualified candidates Virtual: This is not a virtual position
• Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized