The Patient Aligned Care Team 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 Transition and Care Management (TCM) Program's Social Work Case Manager provides comprehensive social work service to Post 9/11 transitioning and established Servicemembers and Veterans (SM/Vs) and their families across the continuum of care. 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 http://www.cswe.org/Accreditation 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 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. 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. (a) For appointments at the GS-9 grade level, 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. Most states require two years of post-MSW experience as a prerequisite to taking the licensure/certification exam, and VHA gives social workers one additional year to pass the licensure/certification exam. In states such as California, Washington, and others where the prerequisites for licensure exceed two years, social workers must become licensed at the independent, master's level within one year of meeting the full state prerequisites for licensure. (b) A social worker who does not yet have a license that allows independent practice must be supervised by a licensed independent practitioner of the same discipline who is a VA staff member and who has access to the electronic health record. (c) Different states have different levels of licensure or certification, making it difficult for VHA staff to determine the independent practice level. Each state, Puerto Rico, and the District of Columbia completed surveys identifying the level of licensure or certification allowing independent practice. Copies of the surveys are on file in the VHA Office of Care Management and Social Work Services, and a summary spreadsheet of the levels of licensure or certification is available to social work professional standards board members for purposes of determining whether the social worker's level of licensure or certification meets the VHA qualification standards. All states except California use a series of licensure exams administered by the ASWB. Information can be found at https://www.aswb.org/. The ASWB is the association of boards that regulates social work. ASWB develops and maintains the social work licensing examination used across the country and is a central resource for information on the legal regulation of social work. The ASWB offers three examinations. The master's examination is generally used by states for the independent practice level of licensure or certification, while the advanced generalist and the clinical examinations are used for the advanced practice level of licensure or certification. Differences between the master's and the advanced exams demonstrate the expectation that advanced practice social workers will have a more sophisticated knowledge of practice theory and its application. 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: GS-09 Education, and Licensure: None beyond the basic requirements. Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: 1. Ability to work with Veterans and family members from various socioeconomic, cultural, ethnic, educational, and other diversified backgrounds utilizing counseling skills. 2. 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. 3. 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. 4. 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. 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. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs: 1. Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. 2. 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. 3. 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. 4. 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 5. 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: Outpatient/Inpatient medical and mental health social worker experience. ["VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU Duties include but are not limited to for the PACT incumbent: 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 thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. The incumbent is able to assess functional acuity of the patient and provide appropriate interventions. The incumbent must be able to utilize this assessment in facilitating the Veteran's maximum use of treatment for attainment of the highest level of independence that is possible and practicable. Participate as a member of the interdisciplinary treatment team and actively participate through collaboration with Veterans and family as well as interdisciplinary treatment team members in the development and implementation of treatment goals and interventions. Possess a working knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures, including acute, chronic and traumatic illnesses, substance abuse disorders, common medications and their effects/side effects, and medical terminology. Duties include but are not limited to for the Transition and Care Management Social Worker: The primary responsibility of the position is to ensure the transition of care of Veterans and Active Duty Servicemembers, from the DoD Military Treatment Facilities (MTF) and Warrior Transition Units (WTU) to the Veterans Health Administration (VHA) is safe and continuous. The TCM SW Case Manager supports the Veteran, the Veteran's family, and the Veteran's Caregiver's and coordinates health needs across agencies, sites and unique episodes of care in order to optimize service delivery, improve quality of care, and enhance both patient experiences and outcomes. The incumbent independently provides an array of social work interventions including: high-risk screening, psychosocial assessments, treatment planning, resource education and referral, and case management. These services are provided in healthcare settings, both inpatient and ambulatory. In addition to the clinical and case management responsibilities, the incumbent assists with the public affairs component of the TCM Program's national mission through outreach. The TCM case manager performs clinical interventions and case management services, in collaboration with the other members of the TCM Program, and with guidance from the Interdisciplinary Care Management Review Team (IDCMRT) in order to meet the biological, psychological, and environmental needs of SM/Vs through a well-developed Inter-Agency Comprehensive Plan (ICP) Checklist. When determined by the IDCMRT, the TCM may serve as the Lead Coordinator for assigned patient. Work Schedule: Monday - Friday 7:30am to 4:00pm or 8:00am to 4:30pm (To be determined by the supervisor) Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required"]

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