Social Worker

Summary Social Workers within the Patient Aligned Care Team (PACT) model serve as integral care team members, functioning as care coordinators for an assigned panel of Veterans. They are responsible for assessing and addressing a broad spectrum of biopsychosocial needs that influence health outcomes, including mental health, housing instability, financial hardship, caregiver burden, food insecurity, and access to community resources. Responsibilities The Patient Aligned Care Team (PACT) is a comprehensive, interdisciplinary model designed to provide longitudinal, Veteran-centered primary care with an emphasis on prevention, health promotion, chronic disease management, and care coordination. Within this framework, the social worker functions as an essential care coordinator for an assigned panel of Veterans, ensuring that care aligns with each Veteran's individual needs, goals, and values. Social workers apply advanced clinical skills, and a holistic perspective rooted in the person-in-environment framework to address the full spectrum of biopsychosocial factors influencing Veteran health outcomes. Must have a high level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans in the Primary Care Clinic and/or their families. The incumbent can independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal, and psychosocial problems. Effective social work in the Patient Aligned Care Team context often occurs over a series of several visits and may involve the need of the social worker to visit the Veteran in their home. Independently complete comprehensive, strengths-based psychosocial assessments, incorporating Veteran self-identified concerns and the impact of family, community, housing, and environmental factors. Assess and monitor changes in psychosocial functioning, financial status, housing, food security, and caregiver burden, updating assessments as clinically indicated. Provide case management services across the continuum of care, including coordination of medical, mental health, and community-based services. Apply knowledge of human development across the lifespan to address issues of disability, terminal illness, loss, and grief. Serve as an active member of the interdisciplinary PACT team, collaborating with primary care providers, nurses, pharmacists, behavioral health staff, and specialty Social Workers to develop and implement person-centered care plans. Provide ongoing consultation to team members regarding psychosocial barriers to care and facilitate problem-solving strategies to promote treatment engagement and adherence. Implement evidence-based treatment modalities and therapeutic interventions as appropriate, including psychoeducation, supportive counseling, crisis intervention, and behavioral activation strategies. Conduct diagnostic assessments and psychotherapy under the supervision of an LCSW supervisor, as appropriate to level of licensure. Must understand caregiver stressors, ability to conduct caregiver assessment and provide appropriate caregiver specific interventions. Facilitate timely and appropriate referrals for community placements such as assisted living, group homes, adult day health care, home health, hospice, and nursing home care. Serve as a liaison between the VA, Veterans, caregivers, and community agencies to ensure continuity of care and access to services. Educate Veterans and families on VA and non-VA benefits, community resources, advance directives, and health system navigation. Work Schedule: Monday-Friday; 7:30am-4:00pm (Subject to change based on the needs of the facility) Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases 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 #: 00022F, 00025F 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. 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 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. 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. Social Worker, 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: (a) Ability to utilize a Veteran centric approach when providing interventions and counseling for Veterans, their family members, caregivers, and survivors. (b) 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. (c) 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. (d) Ability to establish and maintain effective working relationships and communicate with clients, staff, and representatives of community agencies. (e) 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. 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: (a) Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. (b) Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, educational, and other backgrounds. (c) 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. (d) 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. (e) 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: At least a year of Medical Social Work Experience. Reference: For more information on this qualification standard, please visit The full performance level of this vacancy is GS-11. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9 to GS-11. Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position. May require standing, lifting, carrying, sitting, stooping, bending, puling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment. Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated. However, the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations. Education Additional Information 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.