Social Worker - Patient Aligned Care Team (PACT)

The PACT Social Worker provides Veteran-centered primary care focused on prevention, health promotion, education, care coordination, clinical services, and chronic disease management. They support Veterans across various primary care areas, help set Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) goals, and deliver comprehensive services using their training and VA/STVHCS policies.

Please note that duty stations include : Audie L. Murphy Memorial Veterans' Hospital, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404 Northeast Bexar VA Clinic 2391 Northeast Loop 410 Suite 309 San Antonio, TX 78217 North West San Antonio VA Clinic, 9939 State Highway 151, San Antonio, TX 78251-1900 Shavano Park VA Clinic, 4350 Lockhill-Selma Road, Suite 200, San Antonio, TX 78249-2166. Major Duties include but are not limited to: - Assist PACT Veterans in navigating care, accessing services, and ensuring follow-up with the PACT team. - Serve as liaison between VA providers and community agencies. - Complete psychosocial assessments and coordinate care, linking Veterans and families with needed resources. - Identify caregiver/family stressors and provide interventions or referrals; determine appropriate case-management level. - Assess at-risk Veterans in crisis, evaluate needs, and initiate safety plans. - Build and maintain professional relationships within VA and community partners. - Provide consultation to staff on Social Work programs. - Educate Veterans on obtaining a PACT provider and using VA services (VVC, MyHealtheVet, Whole Health, Community Care). - Conduct assessments via phone, VVC, or in person. - Provide case management for high-acuity or high-need Veterans (e.g., high CAN scores). - Protect Veteran privacy and confidentiality per policy. - Assess and document signs of abuse, neglect, exploitation, or intimate partner violence. - Participate in facility, VISN, or community committees and work groups. - Demonstrate knowledge of PACT roles, homelessness factors, discharge planning, and community placement options. - Facilitate timely community placements with Veterans, families, and interdisciplinary teams. - Provide consultation to treatment teams on psychosocial factors affecting care and compliance. - Educate Veterans on VA benefits, services, and community/governmental resources. - Promote and complete Advance Care Planning and Advance Directives. - Respond to consults within required timeframes using multiple care modalities. - Follow suicide-risk procedures including C-SSRS, CSRE, Safety Plans, and SBOR completion. - Participate in peer review, case conferences, or research to evaluate Social Work practice. - Support telework, clinic coverage, and care for unassigned Veterans as needed. - Perform additional duties as assigned. Work Schedule: Monday - Friday, 7:30 a.m. - 4: 00 p.m. or 8:00 a.m. - 4:30 p.m. Telework: Ad-hoc telework may be available as determined by the agency policy. Virtual: This is not a virtual position. Functional Statement #: PD53794-F and PD53793-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Pre-Employment Physical: May be required, depending on the needs of the organization Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

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/. NOTE: If your school has changed names, or is no longer in existence, you must provide this information in your application. NOTE: If your school was accredited by the Council on Social Work Education (CSWE) at the time of graduation but is no longer listed on the CSWE website, you must provide documentation of accreditation with your application packet.