Social Worker (Program Coordinator)

Job Title

Major duties include but not limited to:

• Provides comprehensive administrative oversight of the M2VA Program, including planning, policy development, implementation, and evaluation of program goals, procedures, and operations.
• Follows Veterans Health Administration (VHA) policy and develops local processes to identify and track Post-9/11 Servicemembers/Veterans (SM/Vs), using tools such as the OEF/OIF DoD Registry, VIS, VistA, CPRS, CMTRA, NEPEC reports, Classification reports, Patient Data Exchange, and Network Health Exchange.
• Coordinates case management for severely injured or ill Post-9/11 SM/Vs and others with identified needs, collaborating with nurse and social work case managers, VIST Coordinator, SCI Coordinator, Polytrauma Case Manager, and Women Veterans Program Manager.
• Serves as the facility POC for Post-9/11 transition inquiries, healthcare access, and Toxic Exposure Screening (TES). Completes section one of TES screening.
• Responds to Congressional inquiries and VISN/VA Central Office requests.
• Coordinates preventive mental and physical health evaluations for program participants, both at the facility and associated CBOCs.
• Prepares program reports for VA Central Office, VISN leadership, and Medical Center leadership.
• Monitors referral processes between VA facilities, Military Treatment Facilities, and community hospitals to ensure timely inter-facility transfers.
• Oversees Military Treatment Facility referrals and identifies Post-9/11 SM/Vs within the catchment area, ensuring proper registration and collaboration with Enrollment and Eligibility staff.
• Establishes performance and outcome standards aligned with medical center, VISN, and VA Central Office expectations, and documents program effectiveness.
• Ensures policy and procedural compliance with regulatory and accrediting bodies including Joint Commission (JC) and Commission on Accreditation of Rehabilitation Facilities (CARF).
• Researches, disseminates, and analyzes local, state, and national community resources to support continuity of care and enhance Veteran quality of life.
• Identifies unmet needs within the Post-9/11 population and collaborates with facility, VISN, and VA Central Office stakeholders to develop solutions.
• Develops a data-driven continuous quality improvement plan with measurable goals and outcomes.
• Designs and implements outreach strategies to engage Post-9/11 SM/Vs who may benefit from services but are not currently accessing VA care.
• Maintains an ongoing education program for patients, community partners, students, and staff covering clinical practice guidelines, mental health and readjustment issues, psychosocial challenges, and caregiver concerns relevant to Post-9/11 SM/Vs.
• Performs independent psychosocial assessments and interventions for diverse populations.
• Uses advanced professional judgment, leadership, and social work skills.
• Recognizes the complex needs and challenges associated with military-to-civilian transition, mental health concerns, and multi-agency involvement.
• Conducts thorough assessments examining underlying causes, interpersonal/environmental factors, and barriers to treatment adherence.
• Employs a range of specialized interventions, including individual, group, and family therapy; advanced case management; and evidence-based psychosocial treatments.
• Follows VA Medical Center protocols in emergencies, including mandatory reporting to Adult or Child Protective Services.
• Provides on-site crisis facilitation when needed.
• Educates Veterans and families regarding VA and community benefits, catastrophic disability, Advance Directives, Living Wills, and Goals of Care conversations.
• Facilitates discussions around illness, health care, life changes, and long-term planning.
• Maintains education programs for patients, students, and staff.
• Provides independent, ongoing supportive counseling for Post-9/11 SM/Vs coping with chronic illness, disability, functional decline, catastrophic conditions, or acute stressors.
• Assists Veterans and families with grief and loss associated with illness and end-of-life issues.
• Coordinates referrals to Mental Health and PCMHI as needed.
• Acts as an advocate to help Veterans navigate complex systems or bureaucratic challenges.
• Promotes self-advocacy to support independence and empowerment.
• Screens all Post-9/11 SM/Vs for case management needs and provides services when indicated.
• Applies lifespan developmental principles and supports Veterans dealing with grief, disability, or terminal illness.
• Coordinates care delivery across settings and provides psychosocial and psychiatric assessments within clinical privileges.
• Provides direct patient care.

Work Schedule: 8:00am - 4:30pm Monday - Friday Telework: This position is eligible for telework on an Ad-Hoc Basis per agency policy Financial Disclosure Report: Not required