The VA Nebraska-Western Iowa Health Care System is recruiting for one (1) full-time Social Worker for the Primary Care Service Line (Post 9/11 Transition Care Management). This position is located at the Grand Island VA Medical Center. The Post 9/11Transition and Care Management (TCM) Program's Social Work Case Manager provides comprehensive social work service to Post 9/11 transitioning and established Service members and Veterans (SM/Vs) and their families across the continuum of care and during the various phases of readjustment to civilian life. The incumbent independently provides an array of social work interventions including: high-risk screening, psychosocial assessments, treatment planning, resource education and referral, and case management. These services are provided in healthcare settings, both inpatient and ambulatory. In addition to the clinical and case management responsibilities, the incumbent assists with the public affairs component of the TCM Program's national mission through outreach. The primary responsibility of the position is to ensure the transition of care of Veterans and Active Duty Service members, 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 Post 9/11TCM 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. Responsibilities include, but are 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. Uses the social work process (psychosocial assessment, diagnosis, and treatment) in collaboration with interdisciplinary team members to develop holistic case management plans and psychosocial interventions. 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. In addition uploads 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. Participates in the orientation, training, and teaching of social work graduate students and other trainees and staff Conducts and/or participates in research and/or program evaluation as appropriate. Supports the mission, policies, and procedures of VA, the Veterans Health Administration (VHA), the appropriate Veterans Integrated Service Network (VISN), and the facility. May serve on committees, work groups, and task forces at the facility, VISN, and/or VA Central Office levels. Accountable for furthering own professional growth through education, appropriate to area of assignment, and providing coverage during social worker absences. Must maintain a level of productivity and quality consistent with facility and Social Work standards and the complexity of the assignment. Participates in IDCMRT meetings, appropriate facility meetings, and Social Work meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to the field of Social work. PLEASE SEE BELOW FOR QUALIFICATION REQUIREMENTS Work Schedule: Monday - Friday, 8:00 a.m. - 4:30 p.m. (With some weekend and evening hours as needed. TOD is negotiable) Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.