Social Worker - Community Living Center Discharge Planner

The incumbent will provide medical Social Work services to the Veteran population within Geriatrics and Extended Care (GEC), primarily providing discharge planning services for the Community Living Center (CLC) at Dom VA Medical Center. Services include provision of high-quality case management, clinical treatment, advocacy, and coordination of linkages to other appropriate VA or community service providers.

Duties may include but not limited to: Develops an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others. Develops and demonstrates an understanding of the range of treatment and skills needed for all adult patients including geriatric patients related to their physical limitations, psychological needs and age associated illnesses and conditions. Develops a treatment plan with the Veteran, based on their assessment/screening. Develops the treatment plan and discharge plan and setting achievable treatment/discharge goals with the Veteran/family. Attends treatment team meetings and complete all MOS entries and the Social Work Care Plan for team meetings in a comprehensive and timely manner. Reviews discharge plans weekly, and communicates discharge needs to all members of the treatment team as appropriate. Collaborates with other service providers in assessing and reassessing the Veteran's needs. Educates the Veteran, family and or significant others of the available services and assisting them in establishing the appropriate referrals based on the Veteran's preference or that of his surrogate decision-maker. Makes rapid assessments and develops crisis management plans for admission to mental health inpatient programs when appropriate. Provides education related to VA and community resources, entitlements, Advanced Directives/Living Will and will refer Veterans/families to the appropriate interdisciplinary team member for identified health education needs. Provides the Veterans and their caregivers with ongoing supportive counseling. Enters all Veteran/family contacts in the electronic record using appropriate formats and templates. Establishes and maintains positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. Performs other duties as required. Work Schedule: Monday-Friday, 8:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 58847F & 58843F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. 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.