The Transition and Care Management (TCM) Program Coordinator oversees all transition activities and the coordination of care and services for all Post 9/11 service members (SM) and Veterans (V) treated at Northern Arizona VA Health Care System. Post 9/11 SMN come from a wide geographic area. Their health care and psychosocial problems and needs are complex and require a high degree of clinical oversight and creative problem solving. Duties of this position include but are not limited to: Serves as the facility point of contact for all inquiries regarding transition of Post 9/11 SMNs and as point of contact for Post 9/11 SMN seeking health care from the facility. These duties include outreaching a wide variety of stakeholders (e.g. Veterans, families, state and community agencies, Veterans Service Organizations, military support programs). Incumbent addresses Congressional inquiries and VISN and VA Central Office action items as requested. Oversees or works closely with facility care management teams to include but not limited to nurse and social worker case managers, the Visual Impairment Services Team (VIST) Coordinator, the Spinal Cord Injury (SCI) Coordinator and the Women Veterans Program (I/WP) Coordinator. Serves as facility Point of Contact for Polytrauma patients. Ensures Post 9/11 SMN receive comprehensive preventive mental and physical health evaluations. Incumbent accomplishes this by establishing collaborative relationships with physicians, psychologists, nurses, social workers, and other disciplines to foster their involvement in the care of Veterans in the TCM Program. Planning, establishing, and implementing policies and procedures; developing program goals and objectives; and monitoring, operating, and evaluating the functioning of the program. Ensures that all Post 9/11 SMN are screened for the need for care management services and that those in need of nurse and/or social worker Case Managers are assigned accordingly, particularly those who are severely injured or ill. Coordinates psychosocial evaluation, assessment, and periodic reassessments of all Post 9/11SMN who are actively being case managed. Establishes and maintains an ongoing education program for patients, community agencies, students, and staff to facilitate understanding of medical treatment, including clinical practice guidelines, mental health issues, readjustment issues, psychosocial problems, and care giver issues facing Post 9/11 SMN. Uses the social work process (psychosocial assessment, diagnosis, and treatment) in collaboration with interdisciplinary team members to develop a care management plan and psychosocial interventions. Evaluates the need for mental health services and makes appropriate referrals for individual, group, couples, and family treatment services. Must be sensitive to the ethnic and cultural diversity and age-specific challenges Post 9/11 SMN and adjusts intervention and treatment plans as appropriate. Work Schedule: Monday - Friday, 8:00 a.m. through 4:30 p.m. Financial Disclosure Report: Not require.
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.