Social Worker (Mental Health Treatment Coordinator)

Summary Works for the Central Virginia VA Health Care System, Fredericksburg Health Care Center (FxHCC) and is assigned to the Behavioral Health Interdisciplinary Program (BHIP). Duty location is: 10432 Patriot Highway Fredericksburg, VA 22408-2628. Responsibilities Serves in the role of the Mental Health Treatment Coordinator (MHTC), also referred to as Care Coordinator. Care coordination is a system-wide approach to the deliberate organization of all Veteran care activities between two or more participants or systems to facilitate the appropriate delivery of health care services. Care coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a Veteran's care to achieve safer and more effective care. This means the Veteran's needs and preferences are known ahead of time and communicated at the right time to the right people, and this information is used to provide safe, appropriate, and effective care to the Veteran. The position is fully dedicated to care coordination and serves as a point of contact (POC) for Veterans receiving mental health care (other than brief mental and behavioral health care provided in integrated care settings) across the mental health continuum of care. The primary role of the MHTC is care coordination, not direct care provision (e.g., ongoing psychotherapy). The MHTC ensures Veterans receiving MH care on a BHIP team have continuity throughout their mental health care and affords Veterans a consistent POC, especially during care transitions. Ongoing POC and clinical resource that promotes treatment engagement, especially during care transitions along the MH continuum of care. Provides and/or ensures the Veteran (and family/caregiver/support person) has access to education, information, and resources for proactive self-management. Complete MH Care Coordination needs assessment. Develops initial MH Care Coordination interventions plan, including intended frequency of contact, as part of the overall care plan Documents needs assessments and interventions plan in the electronic health record (EHR). Monitors MH Care Coordination and treatment needs and adjusts the MH Care Coordination interventions plan, in collaboration with BHIP providers, as needed over time. Communicates with the Patient Centered Management Module (PCMM) coordinator to ensure all MHTC assignments are current and visible in the EHR. Participates in frequent team huddles (e.g., daily) and team meetings (e.g., weekly) helps to organize flow of team huddle. Outreaches or facilitates outreach to Veteran to promote care continuity when other team members are unavailable (e.g., triage Veteran needs). Provides information/education to other healthcare and service providers to facilitate recognizing and respecting the Veteran's needs, strengths, and goals. Coordinates care within and beyond the BHIP team by including BHIP team members, other VHA healthcare providers, and community providers to ensure that key components of mental health care delivery occur consistent with policy. Responds to critical events (e.g., ED/UCC visits, inpatient stays, suicide behaviors, accidents, etc.) as they are known by gathering information, updating the team, coordinating any additional care or changes to care, and following up with the Veteran as needed. Is available to the Veteran to answer questions about needs, upcoming visits, care plans, and other questions not already handled by BHIP treating provider(s). Flexibly provides same-day access and walk-in services (i.e., triage) and either address immediate needs that do not require a treating team provider or facilitate a hand off to a treating team provider. Aids in crisis intervention, as needed (e.g., manages medical and mental health emergencies appropriately, including suicidal and homicidal ideation). Facilitates urgent appointments and warm handoffs, as needed, with BHIP team members. Ensures Veteran receive needed care through ensuring consult initiation and follow-up. Ensures consults are entered or referrals are made to providers, services, and resources appropriate to the Veteran's needs. Monitors whether referrals made by the BHIP team to other resources are completed and whether the Veteran is engaged in the planned level of care. Attempts outreach to the Veteran to try to increase treatment engagement. Educates the Veteran on the team model and the Veteran's active role on the BHIP team. Work Schedule: Monday - Friday, 8am-4:30pm Recruitment/Relocation Incentives: Not Authorized Telework: Ad Hoc, as determined by the agency policy Virtual: This is not a virtual position. VA Careers - Social Work: VA Careers - Licensed Clinical Social Worker: Total Rewards of a Allied Health Professional Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. 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. 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). A doctoral degree in social work may not be substituted for the master's degree in social work. Experience/Licensure: Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non-VA experience) and licensure or certification in a state at the independent practice level. In addition to the above, the following experience must be demonstrated: Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, cultural, ethnic, educational and other diversified backgrounds. Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e. acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan. Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals. Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment. References: VA HANDBOOK 5005/120 PART II APPENDIX G39 The full performance level of this vacancy is GS-11. 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: 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: Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.