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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 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. 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. 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. Preferred Experience: Outpatient/Inpatient medical and mental health social worker experience. Applicants with the following certifications from American Heart Association (AHA) or Military Training Network (MTN) are highly preferred: Basic Life Support (BLS). The selected employee will be required to receive certification prior to assuming clinical responsibilities and ensure current certification after employment is maintained. Grade Determinations:GS-9 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: 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. 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: 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. References: VA Handbook 5005, Part II, Appendix G39 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: The work is sedentary. Typically, the employee sits comfortably to perform the work. However, there may be some walking; standing; bending; carrying of light items such as papers, books, small parts; or driving an automobile, etc. No special physical demands are required to perform the work. ["VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU Duties include but are not limited to: 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. Facilitate 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. Ability to conduct caregiver assessment and provide appropriate caregiver specific interventions. Serve as a liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services. Implement treatment modalities and evidence based practices as well as provide educational classes, and/or supportive groups for Veterans and families, including shared medical appointments. Provide consultation and education to Veterans and their families regarding community resources, VA benefits and specialty programs, and Advance Directives. This includes the incumbent's 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. Provide consultation to other treatment team 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. Make appropriate referrals to community and other governmental programs or agencies. Provide case management services to Veterans and their families throughout the continuum of care. The incumbent will be able to appropriately utilize principles of human growth and development over the life span and will be able to assist Veterans in coping with the loss and grief experiences from disability and terminal illness. 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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