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    The VA Northern California Health Care System is recruiting for a Senior Social Worker to service in the Transition of Care program within Primary Care. The incumbent will address the Veteran's bio-psychosocial status, social system and resources. They will further develop and maintain a therapeutic relationship with the Veteran which may include linking the Veteran with systems that provide needed services, resources and opportunities.

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    • Supports the Veteran, the Veteran's family, and the Veteran's caregiver's health needs across episodes of care both within and outside the VA health care system in order to ensure the Veteran receives the highest level of quality, satisfaction and cost effective outcomes as possible.
    • Develops rapport with community hospitals providing care to veterans such that care coordination during transition is optimized.
    • Interacts with members of the health care team within a facility while assessing, communicating, facilitating care, and advocating. Communication is an integral part of this role, including but not limited to face-to-face and telephonic communication, written communication within the electronic health record, and in other inter- and intra-facility documents as appropriate.
    • Communicates with unit staff to identify learning needs specific to the Veteran and discharge planning needs, especially those unique or essential to a Veteran's health condition or care situation.
    • Possesses a working knowledge of medical and mental health diagnoses, disabilities, and treatment procedures, including acute, chronic and traumatic illnesses, substance abuse disorders, bereavement, common medications, and general medical terminology.
    • Facilitates communication between the Veteran, the Veteran's family/caregiver, VA health care providers, and among the Veteran's various health care providers.
    • Establishes, in collaboration with key stakeholders (e.g., providers, payers, employers, family, and significant others), comprehensive case management goals, objectives, and expected outcomes including specified times frames.
    • Conducts thorough assessments to determine psychosocial problems that cause distress, often impacting the health condition and creating barriers to care needs of Veterans and family members, the underlying causes of the presenting problem, the interpersonal and environmental factors impacting the problem, and its effect on the patient's ability and desire to comply with the treatment recommendations.
    • Alerts RN and pharmacist when physical symptoms and medication concerns are noted during the psychosocial assessment.
    • Helps the Veteran and family understand the contributing factors to the problem(s), discusses with them the pros and cons of possible short-term and long-term solutions, and encourages them to make positive and lasting changes to reduce stressors.
    • Possesses a thorough knowledge of community agencies that are covered by Medicare, Medi-Cal, and VA pay to ensure Veterans receive the services they need with the least amount of financial burden.
    • Provides consultation and education to Veterans and their families regarding community resources, VA benefits and specialty programs, and advance directives/LSTD. This includes the incumbent's knowledge of the process for accessing and/or coordinating community-based services, including information and referral for additional services from other VA programs, other government programs, and community programs.
    • Identifies appropriate resources and provides referrals to various service resources along a continuum of care to restore or maintain Veterans independent functioning to the fullest extent possible.
    • Shares data and information, seeks clarification, individualizes treatment plans and interventions, and monitors outcomes of the Veteran's treatment and effectiveness of the program.
    • Collaborates with the health care team to ensure acquisition of the appropriate non-skilled services and community resources necessary to meet the unique health and psychosocial needs of the Veteran.
    • Plans and implements services through coordination, collaboration, and communication with the multi and or interdisciplinary team including VA and non-VA providers.
    • Utilizes evidence-based practice guidelines in development of the case management treatment plan.
    • Ensures timely access to the appropriate level of care by coordinating comprehensive referrals and transitioning the Veteran to VA, DoD, other federal, state, and local home and community-based services.
    • Communicates and coordinates care with the PACT RN Care Manager, PACT Social Worker, and with other specialty care team members.
    • Upon discharge of the Veteran from case management services, transfers full responsibility to the PACT RN Care Manager or other appropriate PACT members for the care of the Veteran.
    • Demonstrates the ability to train and mentor staff in this special area of practice and to provide supervision for advanced licensure.
    • Demonstrates the ability to be a field instructor for social work graduate students who are completing VHA field placements.
    • Serves on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor or Chief of Primary Care.

    Travel Required

    Not required

    Supervisory status


    Promotion Potential


This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/582908500. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.