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Summary 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 as its focus: prevention; health promotion, coordination, and chronic disease management. The social worker functions as a PACT teamlette member with a panel of veterans to ensure that health care meets their needs, as defined by the veteran. Responsibilities Work Schedule: Monday - Friday; 8:00 a.m. - 4:30 p.m.; Tour of duty subject to change to meet the needs of the Agency Telework: This position is not eligible for Telework Virtual: This is not a virtual position. Functional Statement #: 07673-F Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Financial Disclosure Report: Not required Major duties for the position include, but are not limited to: Independently works with veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, and psychosocial problems. Frequently offers consultation to colleagues and students on the psychosocial treatment and care coordination of complex patients as incumbent is seen as an expert and leader among peers in the psychosocial care of medically complex patients. Possesses a working knowledge of medical and mental health diagnoses, disabilities, and treatment procedures, including acute, chronic, and traumatic illnesses, substance abuse disorders, bereavement, common medications, and general medical terminology. Medical conditions include but are not limited to dementia (including Alzheimer's and Lewy-Body's), CVA (cardiovascular accident, aka "stroke"), DM Type I (diabetes mellitus), COPD (chronic obstructive pulmonary disease), TBI (traumatic brain injury), CHF (congestive heart failure), AKA and BKA (leg amputation), CKD and ESRD (kidney disease), and cancer. Mental health conditions include but are not limited to depressive disorders, anxiety disorders (including PTSD), substance abuse disorders, personality disorders, and psychotic disorders (including bipolar I and schizophrenia). Most prescribed medications for these stated conditions include but are not limited to benzodiazepines (for anxiety), SSRI's and SNRI's (for depression and anxiety), anti-psychotic medications, potassium-sparing diuretics (for heart issues), chemotherapy and radiation (for cancer), and cholinesterase inhibitors (for dementia). Possesses a high level of skill and expertise to establish and maintain effective therapeutic relationships with, and in assessing and treating the complicated psychosocial problems of, veterans and their families/significant others. Actively participates as a member of the interdisciplinary treatment team through collaboration with veterans and family as well as interdisciplinary treatment team members to formulate and implement a treatment plan, identifying the patient's problems, strengths, weaknesses, coping skills and assistance needed. Accepts referrals originating from any member of the interdisciplinary team, from Veterans and/or their families who call or walk-in for assistance, and from community professionals. Conducts thorough assessments to determine psychosocial problems that cause distress, often impacting the health condition and creating barriers to care needs of veterans and family members, the underlying causes of the presenting problem, 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. These stressors can include adjustment to the current medical condition, untreated or under-treated mental health or substance abuse conditions, economic instability, legal problems, and inadequate housing and transportation. Provides consultation and education to veterans and their families regarding community resources, VA benefits and specialty programs, and advance directives. This includes the incumbent's knowledge of the process for accessing and/or coordinating community-based services, including information and referral for additional services from other VA programs, other government programs, and community programs. Possesses a thorough knowledge of community agencies that are covered by Medicare, MediCal, and VA pay to ensure veterans receive the services they need with the least amount of financial burden. Helps the patient and family to understand the contributing factors to the problem(s) and discusses 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. Provides wellness/prevention education and stress management, which includes expertise in Whole Health, facilitates patient/family support groups or clinical groups, independently or in conjunction with other clinical providers, and participates in shared medical appointments as appropriate. Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. 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 dentification 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. Qualifications 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. 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. 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. English Language Proficiency: Social workers must be proficient in spoken and written English in accordance with VA Handbook 5005, Part II, chapter 3, section A, paragraph 3j, this part. 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). Grade Determinations: Senior Social Worker, GS-12: Experience/Education: The candidate must have at least two years of experience post advanced practice clinical licensure and should be in a specialized area of social work practice of which, one year must be equivalent to the GS-11 grade level. Senior social workers have experience that demonstrates possession of advanced practice skills and judgment. Senior social workers are experts in their specialized area of practice. Senior social workers may have certification or other post-masters training from a nationally recognized professional organization or university that includes a defined curriculum/course of study and internship or equivalent supervised professional experience in a specialty. Licensure/Certification: Senior social workers must be licensed or certified by a state at the advanced practice level which included an advanced generalist or clinical examination, unless they are grandfathered by the state in which they are licensed to practice at the advanced practice level (except for licenses issued in California, which administers its own clinical examination for advanced practice), and they must be able to provide supervision for licensure. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, candidates must demonstrate all of the following KSAs: Skill in a range of specialized interventions and treatment modalities used in specialty treatment programs or with special patient populations. This includes individual, group, and/or family counseling or psychotherapy and advanced level psychosocial and/or case management. Ability to incorporate complex multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice. Knowledge in developing and implementing methods for measuring effectiveness of social work practice and services in the specialty area, utilizing outcome evaluations to improve treatment services and to design system changes. Ability to provide specialized consultation to colleagues and students on the psychosocial treatment of patients in the service delivery area, as well as role modeling effective social work practice skills. Ability to expand clinical knowledge in the social work profession, and to write policies, procedures, and/or practice guidelines pertaining to the service delivery area. References: VA Handbook 5005/120, Part II, Appendix G39, Social Worker Qualification Standard, GS-0185, Veterans Health Administration, dated September 10, 2019. Driver's License: This position requires operation of a motor vehicle. If selected, the candidate must possess a current unrestricted state issued driver's license. The full performance level of this vacancy is GS-12. The actual grade at which an applicant may be selected for this vacancy is a GS-12. Physical Requirements: This position requires light lifting, use of fingers, walking, standing, ability to distinguish basic colors, ability to distinguish shades of colors, hearing (Aid permitted), and operation of a motor vehicle. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.