Social Worker - Patient Aligned Care Team

Department of Veterans Affairs

This position is utilized as part of a team that supports Patient Aligned Care Team (PACT)/ Primary Care functions, and is expected to work on site at The Villages on Mulberry Lane. The Clinical Social Worker is able to formulate and implement a treatment plan, identifying the patient's problems, strengths, needs, abilities, and challenges with the patient, family and interdisciplinary treatment team.

• This position supports the PACT - Patient Aligned Care Team. The Clinical Social Worker possesses the skills to offer psychosocial interventions including the provision of short-term, solution-focused supportive counseling with Veterans and their family members/significant others/caregivers. Social Worker is responsible for reviewing and coordinating all phases across the continuum of care, this includes primary care, specialty care, mental health care, acute care, extended care, and others. Duties may include, but are not limited to: Knowledgeable of the range of treatment and skills needed for all adult patients including mental health patients related to their physical limitations, psychological needs and age associated illnesses and conditions. Evaluate the need for Veterans to be referred for capacity exams (neuropsycholgical assessments, payee, fiduciary, etc.) through the Primary Care or Mental Health Provider. Identifies family/caregiver stressors and makes referrals to both VA and community resources to reduce caregiver burnout and support families and caregivers in providing care for Veterans. Assesses for any signs or symptoms of abuse, neglect, or exploitation and follows required local policies regarding mandatory reporting and documentation. Must be knowledgeable of various mental health diagnoses and understand the diversification of the mental health within the Veteran population, being sensitive to human growth and development, age-appropriate needs and concerns. Screen and assess for suicide risk to provide vital access to services for Veterans who may be experiencing suicidal ideations and be in need of care. Provides case management and care coordination to facilitate appropriate delivery of health care services, incorporating complex multiple causation in differential diagnosis and treatment of Veterans and making psychosocial and/or mental health diagnoses within approved clinical privileges or scope of practice. Knowledgeable regarding the continuum of care and is able to evaluate required level Properly document and scan records to ensure clear and accurate information regarding the Veterans' wishes are available in the electronic health record. Proactively addresses the goals of care conversations, discussing role of the surrogate, eliciting understanding of diagnosis and prognosis, eliciting patient's values, goals, providing basic information about LSTs & services, and documenting the conversation. Preferred Experience: Experience in independently assesses the psychosocial functions and needs of individuals and families from diverse backgrounds. Able to formulate and implement a treatment plan, identifying the patient's problems, strength's, needs, challenges and coping skills. Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. Total Rewards of a Allied Health Professional Work Schedule: Selected new hire is able to pick one of these shifts: Monday - Friday 730am to 4pm, 8am to 430pm, or 8:30AM to 5PM Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 51910F / 51909F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized EDRP Authorized: Not authorized Additional Benefits Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

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