Social Worker (PACT)

Summary The Patient Aligned Care Team (PACT) Social Worker is part of a comprehensive team which delivers primary care to Veterans in either a longitudinal or episodic fashion, which has its focus on the following: prevention, health promotion, psychoeducation, care coordination, direct clinical services, and chronic disease case management. The Social Worker assigned to PACT can be assigned to different Primary care areas such as: Specialty Outpatient Medicine, Geriatrics, Homeless, and Community Care. Responsibilities Duties may include but are not limited to: The incumbent has the primary responsibility to assist PACT Veterans with navigating care, facilitating access to care, and follow-up with the PACT team to ensure appropriate care is being provided; Serves as the liaison between community agencies and VA providers; Complete psychosocial assessments and coordinate care to facilitate the most appropriate delivery of health care services, while linking the Veteran and/or their families with services, resources and opportunities in order to maximize their knowledge, independence, health and well-being; Identifies family/caregiver stressors and conducts assessments and provides specific interventions or referrals on their behalf. The incumbent will determinate appropriate level of case management being offered based on Veterans' level of acuity for Veterans' psychosocial circumstances; Completes assessments timely for at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plans in consultation with their supervisor; Establish and maintain professional interactions and relationships with stakeholders both within the VA and the community; Act as a consultant to other team/staff members in regard to different Social Work program areas; Provide education for the Veteran on how to get assigned a PACT provider; Complete assessments via phone, VVC, or face to face; Provide case management to Veterans with high care assessment need (CAN) scores or other complex needs; Uses clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies, handbooks or directives; Assess and document identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence; Serve on committees, work groups, and task forces at the facility and/or Veterans Integrated Service Network (VISN) level and/or in the community; 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. This incumbent will be able to identify contributing factors of homelessness, discharge planning, placement/treatment options in the community, and referrals for non-institutional services; Facilitates action for community placements through collaboration with Veterans and their families, as well as interdisciplinary treatment team members to ensure that appropriate community placements are completed in a timely manner; Provides education to Veterans and families in regard to My HealtheVET, Whole Health program, and Community Care options; Provides consultation to other treatments teams and staff members regarding psychosocial needs of Veterans and/or their families and the impact of the identified psychosocial problems on the Veteran's health care planning and compliance with treatment; Educate Veterans regarding VA benefits and VA services, community resources, and process for making appropriate referrals to community and other governmental programs or agencies; Utilize and promotes group, individual, and phone education to complete Advance Care Planning (ACP) and/or Advance Directives in the PACT clinic; Responsive to consults within established time frames and actively works to meet Veteran's psychosocial needs through face to face, phone or telehealth appointments; Educates Veterans on the use of VA Virtual/Video Connect (VVC) clinics effectively; Follows STVHCS standard operating procedures for evaluating and mitigating suicide risk to include: Completes the Columbia Suicide Severity Risk Scale (C-SSRS) annually or more often as indicated, the Comprehensive Suicide Risk Evaluation, and a Safety Plan via shared template in the Computerized Patient Record System (CPRS) on all patients at intake, with Veterans with suicidal ideation and on any Veteran whose record is flagged "High Risk for Suicide." Additionally, completes the Suicide Behavior and Overdose Report (SBOR) as clinically indicated. All clinical decisions will be discussed with clinical supervisor while the incumbent is under supervision; Will include telework, coverage for outpatient clinics, and unassigned Veterans. This position may be assigned to cover clinics within the STVHCS and be required to work at location of clinics during coverage; Performs other duties as assigned. Work Schedule: Monday - Friday, 8:00am - 4:30pm Telework: Ad-hoc only, as determined by the agency policy. Virtual: This is not a virtual position. Functional Statement #: 53793-F; 53794-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized 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 ( 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. Physical Examination: May be required, depending on the needs of the organization. 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: Citizenship: You must be a citizen of the United States English Language Proficiency: You must be proficient in spoken and written English as required by 38 U.S.C. 7403(f) Education and/or Experience Combination: You must possess 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. Note: A doctoral degree in Social Work may NOT be substituted for the master's degree in Social Work. License or Certification* - You must be licensed or certified by a state to independently practice social work at the master's degree level. *Exception - For assignments at the GS-9 level, VHA may waive the licensure or certification requirement for persons who are otherwise qualified, pending completion of state prerequisites for licensure/certification examinations. 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 as a social worker. Grandfather Provision: A Social Worker employed in VHA on the effective date of the qualification standard (9/10/2019) who did not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed, the following provisions apply: Employees may be reassigned, promoted up to and including the full performance (journey) level or changed to lower grade within the occupation but may not be promoted beyond the journeyman level or placed in supervisory or managerial positions. Employees in an occupation that requires a licensure/certification/ registration only at higher grade levels must meet the licensure/ certification/registration requirement before they can be promoted to those higher grade levels. Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended or be reappointed on a temporary or permanent basis until they fully meet the basic requirements of the standard. Employees who are converted to title 38 hybrid status under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of re-entry to the occupation. Employees initially grandfathered into this occupation who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation. Grade Determinations: GS-09: Experience, Education, and Licensure: None beyond the basic requirements. Knowledge, Skills and Abilities: In addition to meeting the basic requirements, to qualify for the GS-09, you must demonstrate the following Knowledge, Skills and Abilities: 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. Licensure Requirement: You must be licensed or certified by a state to independently practice social work at the master's degree level. GS-11 Experience or Education: In addition to meeting the basic requirements, to qualify for the GS-11, you must possess 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. Examples of specialized experience include but are not limited to: Working under close supervision in program areas that do not require specialized knowledge or experience. 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 patient/family member/caregiver advocate with community service providers/agencies; assessing the psychosocial functioning and needs of patients and their family members. In collaboration with the patient, family, and interdisciplinary treatment teams, identifying strengths, weaknesses, coping skills and psychosocial acuity. Maintaining a current network of internal and external resources to educate the patient and/or family members/caregivers and assist with appropriate referrals. -OR- 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. Knowledge, Skills and Abilities: In addition to the experience above, you must demonstrate the following Knowledge, Skills and Abilities: 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: GS-9: Fully licensed at a Master's level Former VA Trainee Prior experience in similar role or with population served GS-11: EBP Certification Prior experience in similar role or with population served Clinical supervision certification Quality or utilization management experience Former VA Trainee Qualifications continued under the Education section: Education Qualifications Continued: 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. Education Accreditation Information: The master's degree must be 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. 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. NOTE: If your school has changed names, or is no longer in existence, you must provide this information in your application. NOTE: If your school was accredited by CSWE at the time of graduation, but is no longer listed on the CSWE website, you must provide documentation of accreditation with your application packet. 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.