Social Worker - Patient Aligned Care Team (PACT)

VA Detroit; Sacramento (CA); On-site; USD 66,000 - 90,000; Full time

Job summary

VA Detroit is seeking a Social Worker for the Patient Aligned Care Team to provide comprehensive care to veterans. This role includes assessment, treatment plan formulation, and community resource coordination. Candidates should have a Master's in Social Work and appropriate licensure, demonstrating the ability to work with diverse populations.

Benefits

Health benefits

Retirement benefits

Paid leave

Qualifications

• Must have a Master's degree in social work from an accredited school.
• Must be licensed or certified to practice social work at the master's degree level.

Responsibilities

• Work independently with veterans and their families experiencing complex psychosocial issues.
• Establish and maintain effective therapeutic relationships.
• Provide psychosocial education regarding community resources and VA benefits.

Skills

Counseling

Assessment

Care Coordination

Community Resource Knowledge

Education

Master's degree in Social Work

Job description

Social Worker - Patient Aligned Care Team (PACT)

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Social Worker - Patient Aligned Care Team (PACT)

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Summary

The Patient Aligned Care Team (PACT) Social Worker 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 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.

Summary

The Patient Aligned Care Team (PACT) Social Worker 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 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.

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Duties

Work Schedule: Monday - Friday; 8:00 a.m. - 4:30 p.m.; Subject to change to meet the needs of the Agency

Telework: Telework not authorized per Agency policy.

Virtual: This is not a virtual position.

Functional Statement #: 000000

Relocation/Recruitment Incentives: May be authorized for highly qualified candidates.

Permanent Change of Station (PCS): Not Authorized

Financial Disclosure Report: Not required

Duties

The Social Worker is assigned to Primary Care and covers Urgent Care and Specialty Clinics as well, where appropriate. Duties include, but are not limited to the following:

• Works independently with veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, and psychosocial problems.
• Establishes and maintains effective therapeutic relationships with, and assesses and treats the complicated psychosocial problems of, veterans and their families.
• Provides psychosocial care of medically complex patients and offers consultation to colleagues and students on the psychosocial treatment and care coordination of complex patients.
• Possesses 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.
• Participates as a member of the interdisciplinary treatment team to formulate and implement treatment plans identifying the patients' problems, strengths, weaknesses, coping skills and any assistance needed.
• Receives referrals from any member of the interdisciplinary team, from veterans and/or their families who call or walkin 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 undertreated 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 requires 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 as well as 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 veterans and families understand the contributing factors to problems and discusses with them the pros and cons of possible short-term and long-term solutions while encouraging them to make positive and lasting changes to reduce stressors.
• Provides wellness/prevention education and stress management, which includes knowledge in Whole Health, facilitates patient/family support groups, and participates in shared medical appointments as appropriate.
• Assists veterans and their families with coping and dealing with the loss and grief experiences in disability, terminal illness, and death.
• Provides case management interventions for veterans with members of the interdisciplinary team in order to coordinate a collaborative effort to meet the agreed upon goals for veterans' treatment needs.
• Facilitates 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.
• Serves as a liaison between veterans, their families, the VA, and community resources in order to ensure thorough delivery of services.
• Represents the VA in the community by preparing presentations for community hospitals and community providers groups.
• Other duties as assigned
  
  

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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.
• You may be required to serve a probationary period.
• 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).
  
  

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 http://www.cswe.org/Accreditation to verify that the social work degree meets the accreditation standards for a Master 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 http://vaww.va.gov/OHRM/T38Hybrid/.
• 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.
• English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C.
• 7403(f).

Grade Determinations:

Social Worker, GS-9

Experience, Education, and Licensure: None beyond the basic requirements.

Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, candidates 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:

Licensure Requirement: You must be licensed or certified by a state to independently practice social work at the master's degree level.

AND

Experience or Education Requirement: In addition to meeting basic requirements, to qualify for the GS-11, you must possess a minimum of one year of post-MSW experience equivalent to the GS-09 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-

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.

AND

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.
  
  

References: VA Handbook 5005, Part II Appendix G39, Social Worker Qualification Standard GS-185 Veterans Health Administration. 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-09 to GS-11.

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. See VA Directive and Handbook 5019, Employee Occupational Health Services.

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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

• Help Help A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
  
  

Review our benefits

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

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Required Documents

To apply for this position, you must provide a complete Application Package which includes:

• License
• Resume
• Transcript
  
  

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

• Cover Letter
• DD-214/ Statement of Service
• Disability Letter (VA)
• License
• Other (1)
• Performance Appraisal
• Professional Certification
• Resume
• SF-15
• SF-50/ Notification of Personnel Action
• Transcript
  
  

NOTE: If you are claiming Agency or Federal Employee Eligibility, you must submit a copy of your most recent (not more than 1 year old) Notification of Personnel Action, SF-50 (Not an award SF-50). Your SF-50 must include:

• Position title, pay plan/series/grade
• Tenure code- Position Occupied
• Type of appointment (Competitive or Excepted)
  
  

If you are relying on your education to meet qualification requirements:

Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Other

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