Social Worker

Quick Facts

• Role: Social Worker (clinical social work in VA community nursing home/extended care settings)

• Schedule: Monday–Friday, 8:00am–4:30pm (subject to change)

• Work model: In-person (not virtual)

Description

The Social Worker provides clinical social work services to Veterans admitted to VA-contracted community nursing homes for long-term care (LTC), short-term rehabilitation (STR), or respite, and monitors Veterans in OPTUM/Community Care Network (CCN) STR facilities within the Columbia VA catchment area. The position includes face-to-face or virtual oversight visits to assess Veteran satisfaction, safety, and quality of care, as well as thorough psychosocial/functional assessments and review of advance directives. Responsibilities also cover case management, clinical oversight, discharge planning support, counseling and crisis intervention, and advocacy with coordination to VA primary care and community resources.

Responsibilities

• Conduct psychosocial assessments and develop psychosocial diagnoses

• Provide case management and care coordination in CNH/LTC/STR settings

• Establish therapeutic relationships with Veterans, families, and skilled nursing facility staff

• Provide individual and family counseling; make appropriate referrals

• Document visits (face-to-face, virtual, or telephonic) per policies

• Assist CNH staff with plans of care and discharge planning

• Assess functional status and determine fitness for continued placement; escalate concerns to the Community Health Nurse

• Refer issues outside scope to the appropriate CNH care manager/coordinator and alert supervisor

• Serve as subject matter expert on VA and community resources; maintain knowledge of program changes

• Coordinate transitions to lower levels of care or home with the CNH Discharge Planner

• Perform rapid crisis assessments and develop crisis management plans; follow protocols

• Process alleged abuse cases per VA and community policy and ensure appropriate notification

• Provide supportive counseling for chronic/disabling illness and end-of-life/institutional and non-institutional care needs; support coping with loss, grief, disability, terminal illness, and death

Benefits

• Competitive salary with regular salary increases; higher step may be available based on qualifications

• Paid Time Off: 37–50 days annual paid time per year (annual leave, sick leave, and federal holidays)

• Parental leave (up to 12 weeks paid after 12 months)

• Child care subsidy (after 60 days, income-eligible employees)

• Retirement: federal pension and 401K with up to 5% contributions

• Insurance: health/vision/dental/term life/long-term care options

• Ability to earn credit toward annual leave accrual based on prior experience or military service