The incumbent monitors the implementation of the national Care Coordination and Integrated Case Management (CCICM) framework, provides coordination and direct clinical evidence-based services within the Care Coordination Review Team (CCRT) and responsible for the clinical programming and daily operations at the VA Caribbean Healthcare System (VACHS). Incumbent's clinical time will be dedicated to PACT Social Work Services working as a Floater.

Duties

Social Work as CCICM Program Coordinator serves a patient population with highly complex health and mental health problems to ensure veterans receive the appropriate level of care case management support based on their prominent need. The SW CCICM PC has both clinical and administrative responsibility to ensure effectiveness of services. application of latest VHA guidelines and modification of service patterns. The incumbent is responsible for planning, development, implementation, monitoring, and evaluation of program operations. SW CCICM Program Coordinator manages and controls the use of data related to CCCM regarding day-to-day functioning and program evaluation. In conjunction with the Service Chief and/or supervisory designee and nursing counterparts, plan, organizes and directs administrative, operational, Veteran and personnel activities for the service. The CCICM framework is a specialized, collaborative practice among multiple healthcare professions that provides structure and standards to support inter-professional collaboration throughout the continuum of care and optimal utilization of healthcare resources. It addresses physical, mental health and psychosocial needs to enhance Veterans' wellness, level of functioning and quality of life. The aim is to provide safe, efficient, and cost-effective interventions integrated throughout the continuum of healthcare. As a PACT Social Work Floater incumbent will provide services in the designated Primary Care Patient Aligned Care Team (PACT) during the absence of other PACT SW providers. Patient Aligned Care Team (PACT) is a comprehensive team which delivers primary care to veterans with the focus of prevention, health promotion, coordination and chronic disease management. Social Worker in PACT clinics must use his/her skills in assessing and treating the psychosocial problems of these Veterans identifying strengths, weaknesses, coping skills and psychosocial acuity, to formulate a plan to meet those needs. Under VICTOR model "Veterans Integrated Care Treatment Optimizing Resilience", social workers' responsibilities includes the assessment of mental health and psychosocial problems, provision of evidence based behavioral interventions and counseling to veterans and/or family members as they go through crisis events or life changing processes. Duties may include, but are not limited to: Provides Direct Patient Care within Primary Care. Implements standardized tools designed to integrate care horizontally and vertically to include, but not limited to, bridging medical care and mental health care, transitioning impatient care and outpatient care, and integrating community care and VA care thereby creating a seamless continuum experience for the Veteran. Develops and implements a facility level framework for implementation of national standardized processes and tools that integrate communication, collaboration and coordination across services and programs to expand upon existing VHA program approaches and address concerns about care coordination service delivery gaps and service duplication. Identifies cohort of Veterans across VACHS with the highest opportunity and highest need and potential areas where care coordination/case management is taking place to include but not limited to primary care, surgical care, mental health, community care, specialty clinics, geriatrics and chronic disease. Integrates inpatient and outpatient care coordinators, care managers and case managers for seamless continuity of care by developing, implementing and monitoring the processes for ongoing screening of identified cohort. Develops and implements facility wide CCICM education plan to key stakeholders to include Service Chiefs, supervisors/managers, frontline staff, and Veterans with plan for ongoing sustainment education plan. Serves as subject matter expert in social work services and the designated expert concerning the provision of case management service. Provides analysis and evaluation or program data and computerized programs to identify system-wide trends and needs to enhance the quality of service across all programs within CCICM framework. Work Schedule: Monday - Friday, 8:00am - 4:30pm Compressed/Flexible: Not available Telework: Not available Virtual: This is not a virtual position Functional Statement #: CCICM Social Work Program Coordinator/PACT SW Floater, FS #62271F

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. 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 to http://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. The following is the standard grandfathering policy for all title 38 hybrid qualification standards. Please carefully review the qualification standard to determine the specific education and/or licensure/certification/registration requirements that apply to this occupation. All persons employed in VHA in this occupation on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series and grade held, including positive education and licensure or certification that are part of the basic requirements of the occupation. For employees who do not meet all of the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Such employees in an occupation that requires a licensure or certification, may be reassigned, promoted up to and including the full performance (journey) level, or changed to lower grade within the occupation, but may not be promoted beyond the journey level or placed in supervisory or managerial positions. Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended or be reappointed, on a temporary or permanent basis, until they fully meet the basic requirements of the standard. Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all of the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation. If an employee who was retained in an occupation listed in 38 U.S.C. § 7401(3) under this provision leaves that occupation, the employee loses protected status and must meet the full VA qualification standard requirements in effect at the time of reentry to the occupation. NOTE: If social workers covered under the grandfathering provision of the 1991 Federal law regarding licensure or certification of VHA social workers leave the GS- 0185 social work series, they lose the grandfathering protection. If they choose to return at a later date to the GS-0185 series, they must be licensed or certified to qualify for employment as a social worker. Grade Determinations: In addition to meeting the basic requirements stated above, the following qualifications must be met in determining the appropriate grade assignment of candidates. GS-12 Social Worker Program Coordinator candidates must have the following: Experience and Education: One (1) year of experience equivalent to the GS-11 grade level. Experience must demonstrate possession of advanced practice skills and judgment, demonstrating progressively more professional competency. Candidate may have certification or other post-master's degree training from a nationally recognized professional organization or university that includes a defined curriculum/course of study and internship, or equivalent supervised professional experience. Licensure/Certification: Individuals assigned as social worker program coordinator must be licensed or certified at the advanced practice level, and must be able to provide supervision for licensure. While we no longer require essay-style responses to our Knowledge's Skills, Abilities, and Other Characteristics (KSAOs), you must be able to demonstrate that you possess the (below) competencies which are necessary to perform the work of the position. Please ensure your resume/CV/application contains sufficient information to support the level of experience/education/training; otherwise, we will not be able to award you credit for the experience/education/training you claim. These are the KSA's for this subject position: Knowledge of program coordination and administration which includes consultation, negotiation, and monitoring. Knowledge and ability to write policies, procedures, and/or practice guidelines for the program. Ability to supervise multidisciplinary staff assigned to the program. Skill in organizing work, setting priorities, meeting multiple deadlines, and evaluating assigned program area(s). Ability to provide training, orientation, and guidance within clinical practice. Preferred Experience: Experience with Care Coordination and Integrated Case Management. Experience in planning, development, implementation, monitoring, and evaluation of program operations. Experience as SW in PACT clinics. Selective Placement Factor (SPF): This position includes a skill, knowledge, ability or other worker characteristic basic to -and essential for- satisfactory performance of the job. Selective Placement Factors are a prerequisite to appointment and represent minimum requirements for a position. Applicants who do not meet it are ineligible for further consideration. Evidence of the Selective Placement Factor must be reflected in your resume. The SPF for this position is: In addition to the English Language Proficiency, you must also be proficient in basic written and spoken Spanish in order to perform the duties of this position. Reference: For more information on this qualification standard, specifically VA Handbook 5005/120, Part II, Appendix G39, Social Worker Qualification Standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-12. Physical Requirements: The work is primarily sedentary, but it may require periods of mobility (e.g., walking, bending, or climbing) and employee may carry light items such as books, instruments, laptops and other similar materials. The work requires emotionally stability, working closely with others emotional stability, mental stability, and working alone. Requires the incumbent to possess or develop an understanding of needs of Veterans. Sensitivity to the special needs of all patients in reference to age, developmental requirements, and culturally related factors must be consistently achieved.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address San Juan VA Medical Center 10 Calle Casia San Juan, PR 00921 US
• Name: Alexander Torelli
• Phone: (561) 422-7553 X27553
• Email: [email protected]