The primary responsibilities of this position are to provide social work services to PACT/GM & Specialty clinics within VA Ann Arbor Ambulatory Care Services. The incumbent is primarily responsible for providing Outpatient Social Work services to Veterans who are receiving medical care predominately in the Patient Aligned Care Team (PACT) clinics.
Duties may include but are not limited to: 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 social work 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. 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 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. Provides treatment intervention 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 for individuals, families, and groups.
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. Coordinates community-based services, including information and referral for additional services from other VA programs, other government programs, and community agency programs.
Provides education to community care partners regarding general VA benefits and services during care coordination for Veterans. Follows Veteran/Caregiver through continuum of health care. 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. Serves as a liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services. Ability to establish and maintain effective therapeutic relationships with Veterans in the Ambulatory Care Clinic and/or their families.
The incumbent is able to work with Veterans and their families who are experiencing a wide range of medical, psychiatric, emotional, behavioral, and psychosocial problems. The incumbent 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.
VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU Work Schedule: Monday-Friday, 8:00 am - 4:30 pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 93964A/ 93965A Permanent Change of Station (PCS): Not Authorized
Social Worker, 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. NOTE: For appointment licensure or certification at this level please refer to paragraph 3c, 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. Demonstrated Knowledge, Skills, and Abilities.
In addition to the experience above, candidates must demonstrate all of the following KSAs: 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, 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. A transcript must be submitted with your application. Note: Only education or degrees recognized by the U.S.
Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education.
For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.
ORLANDO.LANG@VA.GOV · 314-593-1729
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $69716 – $109661/yr.
Applications close on 2026-10-02.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
Apply on official site →