21 Nov
Social Worker

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The Clinical Social Worker in this position provides direct services to adult and geriatric veterans enrolled in the Home Based Primary Care (HBPC) Program with high quality case management, clinical treatment, advocacy, and to coordinate linkage with appropriate VA and community service providers/ agencies as needed by the client. This is accomplished in the collaboration with other members of the HBPC Team.

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This position is responsible for assessment, planning, and provision of case management services in the HBPC Program. The Clinical Social Worker coordinates a variety of activities including outreach, interdisciplinary activities, psychosocial assessments, treatment planning, consultation/education to Medical Center staff and Community Based Service Providers, the collection and maintenance of statistical data, program planning evaluation and modification, and supervision of students as assigned.

Screening/Assessment- The Social Worker will develop an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others, whenever possible. The goal of the assessment is to highlight the Veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the Veteran's functional status and safely maintain the Veteran in his/her home.

Treatment Planning/ Goal Setting: The Social Worker is responsible for contributing to the development of the treatment plan and setting achievable treatment goals with the Veteran, family members/significant others and the other HBPC clinical staff.

Referral to Service Providers: Throughout the course of treatment, the Social Worker is the subject matter expert on VA and/or community resources. The Social Worker will collaborate with the other service providers in reassessing the Veteran's needs for non-institutional, institutional service/programs and entitlements. The Social Worker is responsible for educating the Veteran and families/significant others of the available services and assisting them in establishing the appropriate referrals based on the Veteran's preference or that of his surrogate decision-maker.

Resource Development: The Social Worker is responsible for using the current Social Work resource file of VA and community social service programs and enhancing the content to the benefit of the Veterans. The Social Worker will refer the Veteran to needed services.

Advocacy: The Social Worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the Veteran and family members/significant others. When appropriate and feasible, the Social Worker will educate and encourage the Veteran to advocate on his/her own behalf, thus fostering a sense of independence and empowerment.

Crisis Intervention: The Social Worker is experienced in the making rapid assessments and developing crisis management plans. The Social Worker has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis. In the event of a medical or psychiatric emergency, the Social Worker will follow the protocol of HBPC Program and White River Junction VA Medical Center.

Education/Health Promotion and Prevention: The Social Worker providers education related to VA and community resources, entitlements, Advanced

Directives/Living Will and will refer Veteran and families/significant others to the appropriate interdisciplinary team member for identified health education needs.

Coordination on Non-institutional an Institutional Services: The Social Worker is responsible for the coordination of the referrals on non-institutional services such as HBPC, ADHC/CADHC, home hospice and skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members. The Social Worker is also responsible for the referrals of institutional placement in Adult Homes, Assisted Living Programs, CNH or VA-NHCU. This includes reviewing the progress notes for the other providers to accurately determine the strength and limitations of each Veteran being referred for non-institutional and institutional alternatives.

Supportive Counseling: The Social Worker will provide the Veteran and their caregiver with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illness (es), onset of catastrophic illness and need for non-institutional services, as needed, during the Veteran's enrollment in the HBPC Program.

Administrative Responsibilities: The Social Worker will enter all Veteran/family contacts in the electronic record using appropriate formats and templates. This information will be entered in a complete, confidential, and professional manner to ensure information on the Veteran is shared with other VA staff. This information will be reviewed on a regular basis. The Social Worker will collaborate in the performance improve processes and comply with performance measures as required by the VA for their specific population and/or program. The Social Worker will participate in activities that obtain feedback from clients and work to enhance services as needed.

Work Schedule: Monday-Friday (Shift Varies by needs of the Service)

Financial Disclosure Report: Not required

Travel Required

76% or greater - You may be expected to travel for this position.

Supervisory status


Promotion Potential


  • Job family (Series)

0185 Social Work

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  • Requirements



Conditions of Employment

  • You must be a U.S. Citizen to apply for this job

  • Designated and/or random drug testing may be required

  • Selective Service Registration is required for males born after 12/31/1959

  • You may be required to serve a probationary period

  • Subject to a background/security investigation

  • Must be proficient in written and spoken English

  • Selected applicants will be required to complete an online onboarding process


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.

  • English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. ยง 7403(f).

  • 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/Accreditationxqttzadavcxcbszsqyautyfrbst 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. Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/.

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.

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.

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. The social worker identifies family/caregiver stressors, conducts assessment and provides specific interventions. The incumbent provides case management and care coordination to facilitate appropriate delivery of health care services, incorporates complex multiple causation in differential diagnosis and treatment of Veterans, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice. The social worker links the Veteran with services, resources, and opportunities, in order to maximize the Veteran's independence, health, and well-being. The social worker conducts timely assessment of at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plan as appropriate. The social worker provides interventions independently with Veterans and their families/caregivers who are experiencing a wide range of complicated medical, behavioral health, financial, legal, and psychosocial problems.

References: VA HANDBOOK 5005/120, PART II, APPENDIX G39

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Services.


IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.