Job Title

Summary The Senior Social Worker is a clinician assigned to the Central Texas Veterans Healthcare System Behavioral Health Interdisciplinary Program (BHIP). The Senior Social Worker functions as a Care Coordinator for Veterans on a BHIP team and is responsible for coordination and continuity of care for Veterans receiving services throughout Mental Health & Behavioral Medicine (MHBM). Responsibilities Total Rewards of a Allied Health Professional The Senior Social Worker Care Coordinator provides services for the BHIP including but not limited to biopsychosocial assessment, walk-in/crisis services, education, provision of self-management resources and other clinical tasks as needed for Veterans receiving services in BHIP. Care coordination includes determining and monitoring care coordination needs over time, providing care coordination, and facilitating follow-up and outreach as needed to promote proactive, personalized care and care continuity. Care Coordinators serve as an advocate on behalf of the Veterans on BHIP teams to ensure delivery of comprehensive and seamless care across the care continuum. Direct Patient Care Functions Provides a full range of services within commonly accepted standards of practice and prioritizes care coordination activities as the primary job function [e.g., needs assessment, chart reviews, care or case management (as needed), discharge planning, outreach, etc.] and other services as appropriate. - Provides care coordination (including care management or case management) to Veterans and families, as needed, throughout the continuum of care. This includes communication within and across care lines to facilitate continuity of care for Veterans. - Conducts biopsychosocial assessments to determine care coordination and treatment needs of Veterans. - Provides consultation/education to Veterans and families on VA resources (including self-management tools), community resources, Advance Directives and VA benefits. - Actively participates in the treatment planning process with other disciplines. - Participates in discharge planning with other disciplines and is responsible for ensuring that discharge plans are executed in a manner that is timely and appropriate to promote care continuity. - Acts as a clinical resource/point-of-contact to Veterans and other team/staff members. - Assigns self as Mental Health Treatment Coordinator for Veterans assigned to the BHIP team. - Complies with national and local performance measures, including timely health care screening and completion of clinical reminders for patients. - Complies with national and local performance measures, including timeliness standards for documentation and proper patient check-out procedures (e.g., entering diagnostic and procedure codes, completing encounters, and signing or co-signing notes). - The incumbent will act as liaison between VA and community resources, to include education and bidirectional communication that promotes seamless care. - Provides individual, family and group counseling as appropriate and based on clinic needs. - Provides wellness and prevention education and may facilitate patient and/or family educational supportive sessions as appropriate. - Documents interventions and activities in electronic health record and ensures appropriate hand-off communication and documentation when transferring patient care. - Maintains familiarity and share responsibility with other team members for performance measures relevant to the BHIP team. Work Schedule: Monday through Friday, 7:30 am - 4:00 pm OR 8:00 am - 4:30 pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year). Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Ad-hoc May Be Available Virtual: This is not a virtual position. Functional Statement #: 00000 Permanent Change of Station (PCS): Not Authorized 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