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The Nursing Home to Home Coordinator is a social worker licensed or certified by a state at the advanced practice level. The Social Worker must possess experience demonstrating possession of advanced practice skills including independent and expert clinical psychosocial assessments and case management. The Social Worker must possess experience utilizing independent clinical judgement, and complex practice experience, along with the ability to demonstrate more professional competency. 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). 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/. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Services. English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). Grade Determinations: Social Worker (Program Coordinator), GS-12 Experience/Education. One 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. AND 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. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs: (a) Knowledge of program coordination and administration which includes consultation, negotiation, and monitoring. (b) Knowledge and ability to write policies, procedures, and/or practice guidelines for the program. (c) Ability to supervise multidisciplinary staff assigned to the program. (d) Skill in organizing work, setting priorities, meeting multiple deadlines, and evaluating assigned program area(s). (e) Ability to provide training, orientation, and guidance within clinical practice. Assignments. For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), and variety and be performed by the incumbent at least 25% of the time. Program coordinators at the GS12 grade level are administratively responsible for a clinical program providing treatment to Veterans in a major specialty area, such as but not limited to: Spinal Cord Injury, Homeless Continuum Veteran Program, Hospice and Palliative Care Program, Suicide Prevention Program, Veterans Justice Outreach, Caregiver Support Program and Community Nursing Home Program. The program coordinator may be the sole practitioner in this specialty at the facility and typically provide direct patient care services in the program area. The program coordinator oversees the daily operation of the program, develop policies and procedures for program operation, and prepare reports and statistics for facility, VISN, and national use. They may be responsible for the program's budget, developing and monitoring staff compliance with practice, standards and guidelines on documentation, workload, data entry, ethical practice and service delivery. The program coordinator provides analysis and evaluation of clinical program data and computerized programs to identify system-wide trends and needs to enhance the quality of service. They may be responsible for, or contribute to, the program's resource and fiscal management, monitoring control points developing the annual budget, operating within that budget, and accounting for appropriated funds. The program coordinator is administratively responsible for the clinical programming and prepares reports and statistics for facility, VISN, and national use. They provide leadership, direction, orientation, coaching, in-service training, staff development, and continuing education programs for assigned staff. They initiate and conduct a variety of program or service audits and complete designated clinical practice audits and reports, including productivity assessments. They oversee program operations and evaluations, identifying areas for improvement, gathering relevant data, assessing the data, developing and implementing ideas for improvement and evaluating efficacy of improvement efforts.] Preferred Experience: Experience with Program building. References: VA Handbook 5005/120, Part II, Appendix G39 The actual grade for this vacancy is GS-12. Physical Requirements: This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires a combination of walking (including steps), standing, stooping, kneeling, bending, pulling, and pushing with potentially long periods of sitting. Must be able to safely enter, exit and operate a motor vehicle. ["Program Management The incumbent evaluates and develops necessary policies and procedures to implement and maintain the function of the Nursing Home to Home (NHTH) program in accordance with National guidance. The incumbent administers information and analytical systems to evaluate and enhance the quality of service provided to Veterans in the NHTH program. They are responsible for developing, implementing and overseeing the maintenance of information systems to track service activities including assessments, visits, referrals, Veteran demographics and quality of living, caregiver burden, Veteran safety and Veteran satisfaction. They are responsible for the development, implementation and evaluation of clinical procedures to establish appropriate program and safety procedures consistent with National Office program design. The incumbent will make professional decisions and recommendations for agency action based on tracked and reported utilization of services and referrals, as well as the overall success or failure of program processes and Veteran program enrollment. The incumbent ensures adequate program coverage and makes changes accordingly. The incumbent utilizes all forms of electronic means of communication with Veterans and caregivers to include VA Video Connect (VVC) in order to increase Veteran use of telehealth technologies and access to care. The incumbent ensures that work is completed in a timely manner and reflects quality documentation in accordance with Service, Medical Center, National and The Joint Commission policies and standards. The incumbent directs the assignment of Veterans to NHTH program staff. The incumbent is responsible for clinical Social Work practice in the specialized program to which assigned, including promotion of Social Work services as a key component of treatment. Assessment and Care Coordination The incumbent must possess excellent interpersonal and verbal communication and engagement skills as the incumbent is responsible for initiating Veteran outreach and establishing a continuing relationship with the Veteran, the Veteran's caregiver(s) and/or loved one(s) and involved professionals. The incumbent will complete assessments, utilizing evidence-based tools to evaluate progress, safety and adjustment as outlined by the program design and at other appropriate intervals. The incumbent will collaborate with fellow VA program staff members, as well as non-VA program and facility staff to identify Veterans eligible for assessment and potential participation in the NHTH program. The incumbent will review available medical records utilizing complex clinical judgement to make program eligibility determinations. Further, the incumbent is responsible for facilitating interdisciplinary reviews of Veteran cases and care needs, seeking out appropriate professional input to ensure a comprehensive and safe plan for Veteran discharge to home and in home care and supports. On-Site Visits The incumbent will conduct on-site visits to the Veteran at facility and non-facility settings (e.g., community nursing homes, community-based hospitals and individual residences, etc.) including follow-up visits to oversee care coordination and continue to assess Veteran quality of life, caregiver burden and Veteran safety. The incumbent is responsible for managing the quality control and evaluation of the professional services provided, devising methods of obtaining data and evaluating data to determine the effectiveness of treatment. They are responsible for directing and coordinating clinical and psychosocial services and are accountable for the overall effectiveness of the services provided in collaboration with fellow VA and non-VA programs and services. The incumbent will utilize advanced practice skills to evaluate the treatment needs of the Veteran, make necessary recommendations and changes and to promote appropriate, safe care. Complex Case Review and Data Analysis The incumbent reviews all data, subjective and objective, and makes a clinical assessment, identifying needs and strengths. Effectively uses professional skill, objectivity and insight along with advance clinical training and experience to interpret data and to identify viable treatment options, assesses high risk factors, acuity and need for services. Work Schedule: Monday - Friday, 8:00am to 4:30pm Telework: May be authorized Virtual: This is not a virtual position. Functional Statement #: 56402-O Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required"]

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