What are the responsibilities and job description for the Social Worker-Patient Aligned Care Team position at Association for Home & Hospice Care of North Carolina?
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Social Worker-Patient Aligned Care Team
Veterans Affairs, Veterans Health Administration
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Posted: 08-May-26
Location: Prescott, Arizona
Categories:
Mental Health/Social Services
Internal Number: 868225600
Summary
This professional Social Worker is assigned to Primary Care Teams (PACT) with responsibility to provide social work services to adult Veterans receiving care at the Northern Arizona VA Health Care System. This Social Worker will provide open access to Veterans seeking these services and timely response to individuals in psychosocial crisis in PACT - as well as supporting the behavioral health needs of those in crisis.
Qualifications
Basic Requirements:
- Citizenship: Be a citizen of the United States
- 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/
- 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
- 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)
- 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 utilize a Veteran centric approach when providing interventions and counseling for Veterans - their family members - caregivers - and survivors
- (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
- (3) [Entry Level] Assignments
- Individuals assigned as GS-9 grade level social workers are considered to be at the entry level and are closely supervised - as they are not yet functioning at the independent practice level conferred by independent licensure or certification
- Social workers at the GS-9 entry level are typically assigned to program areas that do not require specialized knowledge or experience
- Duties may include but are not limited to: 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 advocate with appropriate VA and community service providers/agencies when it serves the best interest of the Veteran and family members/caregiver
- assessing the psychosocial functioning and needs of Veterans and their family members identifying the Veteran's strengths - weaknesses - coping skills and psychosocial acuity - in collaboration with the Veteran - family - and interdisciplinary treatment teams
- maintaining a current network of internal and external resources to educate the Veteran and/or family members/caregivers and assist with the appropriate referrals
- Since social workers at this level are not practicing at an independent level - they should not be assigned to program areas where independent practice is required - such as in a CBOC - unless there is a licensed social worker in the program area who can provide supervision for practice
- GS-9 social workers provide psychosocial services in the assigned area under supervision
- 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
- NOTE: For appointment licensure or certification at this level please refer to paragraph 3c
- "Quality of Experience
- Experience is only creditable if it is obtained following graduation with a master's degree in social work and if it includes work as a professional social worker directly related to the position to be filled
- Qualifying experience must also be at a level comparable to social work experience at the next lower 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 - educational - and other 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
- (4) [Full Performance Level] Assignments
- This is the full performance level
- Social workers at this level are licensed or certified to independently practice social work
- Incumbents are assigned to all program areas - including but not limited to: inpatient or outpatient medicine - surgery - mental health - neurology - rehabilitation medicine - and geriatrics
- Employees provide professional - independent social work services in the assigned area
- Duties include but are not limited to: assessing and documenting identified behaviors or symptoms of abuse - neglect - exploitation and/or intimate partner violence
- use of clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies - handbooks or directives
- and acts as an advocate with appropriate VA and community service providers and agencies when it serves the best interest of the Veteran and family members/caregiver
- Incumbent independently assesses the psychosocial functioning and needs of Veterans and their family members - identifying the Veteran's strengths - weaknesses - coping skills - and psychosocial acuity
- In collaboration with the Veteran - family/caregiver - and interdisciplinary treatment team - the social worker facilitates the delivery of health care services
- Continued under "Additional Information"
- NOTE: The 2-page Resume requirement does not apply to this occupational series
- For more information - refer to Required Documents below
- This is an OPEN CONTINUOUS ANNOUNCEMENT and may be posted up to August - 6 - 2026 - OR until vacancy filled
- The initial cut-off date for referral of eligible applications will be May - 21 - 2026 - with subsequent cut-off dates every two weeks until vacancy is filled
- VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU Total Rewards of a Allied Health Professional The Social Worker must possess the knowledge of implementing treatment modalities
- and how to do the following: 1) identify level of functioning - degree of impairment in occupational - social - academic - interpersonal and family area
- 2) evaluate and assess lethality - 3) perform mental status exams (MSE) - 4) identify psychiatric manifestations of various medical conditions - 5) assess and intervene with patients of suspected abuse and provide counseling or psychotherapy for individuals - families and groups
- Major duties include - but are not limited to: Referrals typically originate from professional staff - from Veterans and/or their families seeking assistance - and from community professionals
- Determines the presenting problem - psychosocial factors impacting the problem - and obstacles to treatment and/or follow through with recommended treatments
- Provides social work case management coordination with members of the treatment team - to ensure a collaborative effort to meet the treatment goals for a Veteran
- Acts as a liaison with community professionals regarding needed services for Veterans and/or their families
- Establishes and maintains effective therapeutic relationships with Veterans and/or their families with proficiency
- Works with Veterans and their families experiencing a wide range of complicated medical - psychiatric - emotional - behavioral - and psychosocial problems
- Completes thorough psychosocial assessments to determine the mental health diagnosis - psychosocial functioning and needs of Veterans and/or their families
- Utilizes assessment in developing and implementing a comprehensive treatment plan for attainment of the highest level of independence that is possible and practicable
- Uses demonstrated knowledge of medical and mental health diagnoses - disabilities - and treatment procedures - which includes acute - chronic - and traumatic illnesses/injuries - common medications and their side effects - and medical terminology
- Conducts psychosocial assessments of high-risk patients to identify suicidality through use of the Suicide Risk Assessment (SRA) and other appropriate tools independently
- Participates actively as a member of the interdisciplinary treatment team through collaboration with Veterans and family - in the development and implementation of treatment goals and interventions
- Facilitates 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
- Community placements can involve but are not limited to referrals to contract nursing homes - Community Living Centers - residential care homes - inpatient and outpatient hospice services
- Implements psychotherapeutic treatment modalities - provide educational classes - and/or treatment and supportive groups for Veterans and families based on knowledge and ability
- Provides consultation and education to Veterans and their families regarding community resources - VA benefits and specialty programs - and advance directives - which includes the process for accessing and/or coordinating community-based services - information - and referral for additional services from other VA programs - other government programs - and community programs
- Provides 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
- Maintains knowledge of Veteran's benefits and services - community resources - and process for making appropriate referrals to community and other governmental programs or agencies
- Must possess and demonstrate ability to communicate effectively - both orally and in writing with people from varied backgrounds
- Perform other assigned duties as assigned
- Work Schedule: Monday- Friday - 8:00AM -4:30PM Recruitment Incentive (Sign-on Bonus): May be Available for highly qualified candidates
- Permanent Change of Station (Relocation Assistance): May be Available for highly qualified candidates
- Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Telework: May be Available for highly qualified candidates
- Virtual: This is not a virtual position
- Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized
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About Veterans Affairs, Veterans Health Administration
The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.
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