The Patient Aligned Care Team (PACT) is a comprehensive team which delivers primary care to Veteran patients in a longitudinal rather than episodic fashion and which has its focus: prevention; health promotion, coordination and chronic disease management. The Social Worker in this Veteran centric approach often functions as a care coordinator with a panel of Veterans to ensure that health care meets the needs, as defined by the Veteran. Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. 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. English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f).May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). 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 SW Licensure Summary by State. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Exception: VHA may waive the licensure or certification requirement for persons who are otherwise qualified, pending completion of state prerequisites for licensure/certification examinations. This exception only applies at the GS-9 grade level. For the GS-11 grade level and above, the candidate must be licensed or certified. At the time of appointment, the supervisor, chief social work or social work executive will provide the unlicensed/uncertified social worker with the written requirements for licensure or certification, including the time by which the license or certification must be obtained and the consequences for not becoming licensed or certified by the deadline. (a) For appointments at the GS-9 grade level, VHA social workers who are not licensed or certified at the time of appointment must become licensed or certified at the independent, master's level within three years of their appointment. Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Social Worker, GS-9 (1) Experience, Education, and Licensure. None beyond the basic requirements. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to work with Veterans and family members from various socioeconomic, cultural, ethnic, educational, and other diversified backgrounds utilizing counseling skills. Ability to assess the psychosocial functioning and needs of Veterans and their family members, and to formulate and implement a treatment plan, identifying the Veterans problems, strengths, weaknesses, coping skills, and assistance needed. Ability to implement treatment modalities in working with individuals, families, and groups to achieve treatment goals. This requires judgment and skill in utilizing supportive, problem solving, or crisis intervention techniques. Ability to establish and maintain effective working relationships and communicate with clients, staff, and representatives of community agencies. Fundamental knowledge of medical and mental health diagnoses, disabilities, and treatment procedures. This includes acute, chronic, and traumatic illnesses/injuries; common medications and their effects/side effects; and medical terminology. Social Worker, GS-11 Experience and Licensure. Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non-VA experience) and licensure or certification in a state at the independent practice level. NOTE: For appointment licensure or certification at this level please refer to paragraph 3c. OR Education. In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required one year of professional social work experience in a clinical setting. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs: Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, cultural, ethnic, educational and other diversified backgrounds. Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e. acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan. Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals. Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment. Duties may include but are not limited to: identifying behaviors or symptoms of abuse, neglect or exploitation; providing education on advance directives and advanced care planning; providing social work case management; acting as an advocate with appropriate VA and community service providers/agencies when it serves the best interest of the Veteran and family members/caregiver; assessing the psychosocial functioning and needs of Veterans and their family members identifying the Veteran's strengths, weaknesses, coping skills and psychosocial acuity, in collaboration with the Veteran, family, and interdisciplinary treatment teams; maintaining a current network of internal and external resources to educate the Veteran and/or family members/caregivers and assist with the appropriate referrals. References: VA HANDBOOK 5005/120 PART II APPENDIX G39, Social Worker Qualification Standards. Physical Requirements: This position is primarily sedentary with some bending, walking and stooping required. This may require the employee to walk on uneven surfaces. The position requires the ability to read printed material and distinguish colors, such as reading computer screens, the ability to accurately perceive depth so as to move around work space safety and to appropriately make contact with patients and staff. Considerable walking and stair climbing may be required. The work may also require assisting disabled Veterans. ["Major duties of this position will include, but is not limited to: Uses a high level of skill in assessing and treating the complicated psychosocial problems of Veterans and their families/significant others. Assesses psychosocial problems that cause distress, often impacting the health condition and creating barriers to care. These stressors can include adjustment to the current medical condition, untreated or under- treated mental health or substance abuse condition, economic instability, legal problems, and inadequate housing and transportation. Receives referrals that typically originate from any member of the interdisciplinary team, from Veterans and/or their families who call or walk-in for assistance, and from community professionals. Completes thorough assessments to determine the underlying causes of the presenting problem(s), the interpersonal and environmental factors impacting the problem, and its effect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team. Helps the patient and family to understand the contributing factors to the problem(s), will discuss with them the pros and cons of possible short-term and long-term solutions, encouraging them to make positive and lasting changes to reduce stressors. Coordinates with VA staff and community agencies to assist in problem solving as needed. Provides case management with members of the outpatient interdisciplinary team in order to coordinate a collaborative effort to meet the agreed upon goals for a Veteran's treatment needs and include liaison with community professionals regarding needed services for Veterans and/or their families. Provides following services: a. Interventions to increase access to care, including transportation assistance and Advanced Directives. b. Economic assistance, including assistance with medical bills, financial aid services and strategies to increase income (employment, vocational rehabilitation, VA benefits, disability), and/or reduce expenses. c. Finding the appropriate housing for the patient's level of need (affordable independent housing, homeless shelters, group and family care homes, Veterans Homes, assisted living, nursing homes, respite care, hospice care) and order necessary services to assist with functional decline. Has a high level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans assigned to PACT and/or their families. Has knowledge of the PACT team approach and the role of each health and allied health care team members as well as an understanding of the role of the social worker in the PACT model. Independently completes comprehensive psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. Assesses functional acuity of the patient and provide appropriate interventions and utilizes this assessment in facilitating the Veteran's maximum use of treatment for attainment of the highest level of independence that is possible and practicable. Work Schedule: Full Time, Monday - Friday, 08:00am to 4:30pm 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 existing pay, 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) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. 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: Available Virtual: This is not a virtual position. Functional Statement #: 91551A"]

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