Social Worker (Patient Aligned Care Team)

Social Worker (Patient Aligned Care Team)

Department: Department of Veterans Affairs

Location(s): Cape Girardeau, Missouri

Salary Range: $69213 - $108859 Per Year

Job Summary: John J. Pershing VA Medical Center is a Level-3 Complexity medical center The CLC provides long term care, short-stay continuing care, short-stay rehabilitation, short-stay skilled nursing, respite and end-of-life care. Primary Care, Urgent Care, Ambulatory Specialty Care, Mental Health, Telehealth and Community Health/Home Care are offered by this facility. The main medical center is located in Poplar Bluff, Missouri.

Major Duties:

• Major Duties: Incumbent is a Clinical Social Worker assigned to the Patient Aligned Care Team (PACT). The incumbent must use a high level of skill in assessing and treating the complicated psychosocial problems of Veterans. Social Work responsibilities include the assessment of psychosocial problems, often at a time when the Veteran is experiencing crisis and include the provision of short-term, solution-focused counseling with Veterans, their family members, and/or caregivers. Referrals typically originate from members of the interdisciplinary team, from Veterans and/or their family members/significant others coming as walk-ins to seek assistance, and from community professionals. The incumbent must complete thorough assessments to determine the presenting problem to determine in-home factors impacting the problem and to determine obstacles to treatment and/or follow through with recommended treatments. Consultation with members of the outpatient interdisciplinary team is provided in order to coordinate a collaborative effort to meet the agreed upon goals for the Veteran's treatment needs and include liaison with community professionals regarding needed services for Veterans, their families, and/or caregivers. Working with various patient populations include, but are not limited to, homeless Veterans, Hospice Services, Community Living Center, Home Health services, financial resources, VA benefits, and transportation services. Has primary knowledge of use of medical and mental health diagnoses, disabilities, and treatment procedures. This includes acute, chronic, and traumatic illness, injuries, medical terminology, and common medications and their effects and side effects. Independently identifies high-risk patients and provides case management services for chronic disease management in collaboration with the multidisciplinary team. Complex cases are staffed regularly with the clinical supervisor. Utilizes the Patient Aligned Care Team (PACT) template assessments to synthesize information into a working document that provides direction in determining the level of care, level of case management and follow up. Differentiates between episodic, supportive, progressive and intensive case management. Independently provides crisis intervention services if needed, seeking to address cause, as well as the presenting complaint, coordinates family conferences, and serves as liaison to family members. Formulates a plan with goals, objectives, barriers and needs based on PACT templates for ongoing follow up and case management. Independently conducts psychosocial assessments as appropriate for treatment planning. Assessment is to highlight the Veteran's strengths, limitations, internal and external supports, and service needs in order to optimize functional status. Identifies the psychosocial complications that can be caused due to a sudden onset of an acute or chronic illness. Provides treatment interventions in collaboration with the Veteran and family, interdisciplinary treatment team, and community members. The incumbent possesses knowledge and ability to implement treatment modalities including motivational interviewing (MI) to provide supportive counseling and health coaching to individuals, families, and groups. Incumbent has an understanding of the range of treatment and skills for all adult patients related to illness or chronic medical conditions, psychological needs, and age-associated conditions. Incumbent possesses the skills to establish therapeutic relationships with Veterans and families, mediate difficulties, and measure outcomes of treatment interventions. Provides pro-active case management to assist in eliminating barriers to health care interventions based on the level of case management indicated in the initial and follow up assessments. Offers strategies to resolve underlying causal factors and build upon and promote strengths and abilities. Work Schedule: Monday- Friday 8:00am-4:30pm Telework: Adhoc Telework Only as Needed. Virtual: This is Not a virtual position. Relocation/Recruitment Incentives: NOT Authorized Financial Disclosure Report: Not required

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 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. 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. (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. (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. English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). 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: Social Worker, GS-9 (1) Experience, Education, and Licensure. None beyond the basic requirements (2) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to work with Veterans and family members from various socioeconomic, cultural, ethnic, educational, and other diversified backgrounds utilizing counseling skills. (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 (1) 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 (2) 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. (3) 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, cultural, ethnic, educational and other diversified 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: Minimum 1 year of experience working with high-risk individuals is preferred. Reference: VA Handbook 5005/120, PART II, APPENDIX G39, SOCIAL WORKER QUALIFICATION STANDARD GS-0185 https://www.va.gov/ohrm/QualificationStandards/. 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: This position is mostly sedentary and requires walking, kneeling, bending, standing, and light lifting.

How to Apply: All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 11/21/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12831363. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

Application Deadline: 2025-11-21