Social Worker - Patient Aligned Care Team (PACT)

Veterans Health Administration•San Antonio, TX

2d•Onsite

About The Position

The PACT Social Worker provides Veteran-centered primary care focused on prevention, health promotion, education, care coordination, clinical services, and chronic disease management. They support Veterans across various primary care areas, help set Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) goals, and deliver comprehensive services using their training and VA/STVHCS policies. Duty stations include: Audie L. Murphy Memorial Veterans' Hospital, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404; Northeast Bexar VA Clinic 2391 Northeast Loop 410 Suite 309 San Antonio, TX 78217; North West San Antonio VA Clinic, 9939 State Highway 151, San Antonio, TX 78251-1900; Shavano Park VA Clinic, 4350 Lockhill-Selma Road, Suite 200, San Antonio, TX 78249-2166.

Requirements

Must be a U.S. Citizen.
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.
May be required to complete a Pre-Employment Physical, 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.
Must serve a 1 or 2-year trial period.
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.
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.
GS-9: Demonstrated 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: 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.
GS-11: Demonstrated 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, 8 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.

Nice To Haves

GS-9: Fully licensed at a Master's level
GS-9: Former VA Trainee
GS-9: Prior experience in similar role or with population served
GS-11: EBP Certification
GS-11: Prior experience in similar role or with population served
GS-11: Clinical supervision certification
GS-11: Quality or utilization management experience
GS-11: Former VA Trainee

Responsibilities

Assist PACT Veterans in navigating care, accessing services, and ensuring follow-up with the PACT team.
Serve as liaison between VA providers and community agencies.
Complete psychosocial assessments and coordinate care, linking Veterans and families with needed resources.
Identify caregiver/family stressors and provide interventions or referrals; determine appropriate case-management level.
Assess at-risk Veterans in crisis, evaluate needs, and initiate safety plans.
Build and maintain professional relationships within VA and community partners.
Provide consultation to staff on Social Work programs.
Educate Veterans on obtaining a PACT provider and using VA services (VVC, MyHealtheVet, Whole Health, Community Care).
Conduct assessments via phone, VVC, or in person.
Provide case management for high-acuity or high-need Veterans (e.g., high CAN scores).
Protect Veteran privacy and confidentiality per policy.
Assess and document signs of abuse, neglect, exploitation, or intimate partner violence.
Participate in facility, VISN, or community committees and work groups.
Demonstrate knowledge of PACT roles, homelessness factors, discharge planning, and community placement options.
Facilitate timely community placements with Veterans, families, and interdisciplinary teams.
Provide consultation to treatment teams on psychosocial factors affecting care and compliance.
Educate Veterans on VA benefits, services, and community/governmental resources.
Promote and complete Advance Care Planning and Advance Directives.
Respond to consults within required timeframes using multiple care modalities.
Follow suicide-risk procedures including C-SSRS, CSRE, Safety Plans, and SBOR completion.
Participate in peer review, case conferences, or research to evaluate Social Work practice.
Support telework, clinic coverage, and care for unassigned Veterans as needed.
Perform additional duties as assigned.