Senior Social Worker - Community Care Network, Skilled ...

Summary This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific eligibility requirements per VHA policy and submit your EDRP application within four months of appointment. Program Approval, award amount (up to $200,000) & eligibility period are determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply. Responsibilities The incumbent is the Senior Social Worker of the Community Care Network - Skilled Nursing Facility (CCN-SNF) Rehab Program for the Orlando VA Health Care System. The incumbent is delegated the responsibility and authority for the planning and coordination of all elements which constitute the CCN SNF in collaboration with the Nurse Coordinator partners in the Community Care Department. Duties and functions of the Senior Social Worker, (CCN-SNF) Rehab Program include but are not limited to the following: The incumbent independently reviews the referrals received from community hospitals and other settings and assesses the referrals for administrative and clinical eligibility based on VA guidelines. The incumbent acts as liaison between VA and the community SNFs actively participating with Optum in CCN for admission purposes. The incumbent is responsible for identifying Veterans that will need transitional care prior to discharge home. The incumbent is responsible for overseeing the placement of Veterans into the community SNFs in Optum CCN under VA authorization and assuring that placements meet VA eligibility requirements. The incumbent responsible for independently entering documentation in accordance with medical center policy, ensuring it is completed after each encounter in the Veteran's electronic medical record utilizing the approved program, e.g., CPRS, Consult Toolbox, VistA, HealthShare Referral Manager, Cerner, etc. The incumbent documents independently in the medical records utilizing paper and/or electronic formats, including psychosocial assessments, diagnostics, treatment, progress notes, follow up, and referral. Documentation includes but is not limited to initial evaluations, suicide risk assessments, group notes, care coordination, case management, advanced directives, clinical reminders or initial treatment plans. Highly developed professional, clinical and advanced practice skills are routinely used to assist Veterans with complex problems. The incumbent is responsible for processing orders and authorizations for eligible Veteran placements in accordance with Integrated Veteran Care Field Guidebook guidelines. Verification of the community provider's active status will be confirmed in the Provider Portal Management System (PPMS) maintained by Office of Integrated Veteran Care (IVC) prior to authorization. The incumbent works independently in providing appropriate documentation, review and follow-up of complaints within the CCN SNF Rehab Program. The incumbent provides case management as needed utilizing knowledge of various insurance types (e.g., Medicare, Medicaid, other private health insurances, and VA benefits) to recommend appropriate referrals and discharge plans to community providers. This may include verification of Veteran status and eligibility for participation in VA programs, monitoring admission and discharge dates of participants, reviewing and completing referrals, collecting and submitting Veteran information. The incumbent must be proficient in VA Programs relevant to discharge planning and be knowledgeable of referral processes, eligibility criteria and clinical requirements. Provides both informal and formal education to VA staff, as well as community SNF staff, on any changes in VA policy concerning their specific programs, referral procedures and documentation requirements. The incumbent independently coordinates care including serving as an advocate on behalf of the Veterans admitted to non-VA hospitals, SNFs, or other Vas out of area to ensure comprehensive service delivery and linking and referring Veterans to the VA Healthcare System or community provider. The incumbent engages in coordination with community agencies, organizations, and groups to learn of services or resources available for Veterans with complex needs as well as provides current information on services and benefits available. The incumbent performs accountability functions by documenting all contacts with patients/families in the medical charts and completing other reports in accordance with Orlando VA Healthcare System and respective professional discipline service policies. The incumbent works with Orlando VA Healthcare System multi-disciplinary teams and community agencies to strive to develop more effective and efficient ways of delivering healthcare services. Work Schedule: Monday - Friday; 8:00am - 4:30pm Telework: Ad-hoc - Based on Service needs Virtual: This is not a virtual position. Functional Statement #: 82672F EDRP Authorized: Approved for Education Debt Repayment Program: Learn more (Former EDRP participants ineligible to apply for incentive.) 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

Created: 2026-03-02