Social Worker- Community Nursing Home

Summary The Community Nursing Home (CNH) Social Worker provides oversight, care coordination, and discharge/disposition planning for Community Nursing Home Veterans. Reviews and assists referrals to CNH facilities and performs follow-up and oversight visits after admission to the CNH to ensure adequate and safe care is being provided. Advocates for holistic care through education and provider interaction and implements an educational plan to meet the patient care needs. Responsibilities Total Rewards of a Allied Health Professional Duties and skills needed to be successful in this position include, but are not limited to: The incumbent independently coordinates high-risk patients and provides care management services to Veterans and families. The incumbent participates in the admission screening process and assists in coordinating the admission. The incumbent establishes and maintains effective therapeutic relationships with patients and their families. The incumbent independently works with patients and families who are experiencing a variety of psychiatric, medical, and social problems utilizing individual, group and family counseling and therapy skills. The incumbent conducts psychosocial assessments to determine the needs of Veterans and family members. The incumbent possesses the skills to offer psychosocial interventions and measure outcome to interventions. The incumbent coordinates community-based services, including information and referral for additional services from other VA government, and community agency programs. The incumbent assists with discharge planning from the Community Nursing Home and coordinates with the nursing home, PACT and/or specialty programs to ensure continuity of care. The incumbent independently provides consultation services to other staff regarding the psychosocial needs of Veterans and the impact of psychosocial problem on health care and adherence to treatment plans. The incumbent evaluates their own practice through professional peer review, case conference and other organization means. The incumbent communicates effectively both orally and in writing with people from varied backgrounds. The incumbent develops an assessment of the Veteran in collaboration with interdisciplinary treatment teams, the Veteran, family members and significant others, whenever possible. The incumbent meets the needs of customers while supporting VA missions. The incumbent handles conflict and problems in dealing with consumer constructively and appropriately. The incumbent utilizes word processing, data management, email, CPRS and other computer systems, especially those programs in use by VHA. The incumbent documents all efforts in the electronic medical record in a professional and timely fashion. The incumbent will participate in committee assignments as deemed necessary by the service manager. The incumbent is responsible for assuring that monthly follow-up visits to Veterans in the CNHs are completed and documented utilizing CPRS and ensure appropriate hand off when transferring of patient care, as required by the program. The incumbent is responsible for providing input to the CNH Coordinator and/or Supervisor to assist in assuring that Quality Assurance monitors related to these programs are completed and reported to the CNH Oversight committee. The incumbent is involved in the annual inspection of the nursing homes with lead support provided by the CNH Coordinator and/or Supervisor. Incumbent must possess and maintain a current, valid, and unrestricted state drivers license in order to operate a government owned vehicle. The incumbent performs other duties as assigned. Work Schedule: Monday-Friday, 7:30am-4:00pm 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 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: Ad-Hoc Virtual: This is not a virtual position. Functional Statement #: 56782-A,56783-A Permanent Change of Station (PCS): Not Authorized 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 identification 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 "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. English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). 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 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 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: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. GS-9: 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 utilize a Veteran centric approach when providing interventions and counseling for Veterans, their family members, caregivers, and survivors. 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. 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, educational, and other 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. Preferred Experience: Geriatric or Nursing Home Experience, Interdisciplinary Team Experience, Consult Management, Must possess and maintain an active, unencumbered Driver's License. Reference: For more information on this qualification standard, please visit The full performance level of this vacancy is 11. The actual grade at which an applicant may be selected for this vacancy is in the range of 9 to 11. Physical Requirements: The work is sedentary. Typically, the employee sits comfortably while working. However, there may be some light exertion required when walking, standing, bending, or climbing stairs, carrying of light items such as papers, books, small objects, or driving an automobile. No special physical demands are required to perform the work. Incumbent must possess and maintain a current, valid, and unrestricted state drivers license in order to operate a government owned vehicle Per VA handbook 5003/4, Functional Statements 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: 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: Additional Information Receiving Service Credit for 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.