Social Worker-Outpatient PACT

Summary 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. Responsibilities 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: Total Rewards of a Allied Health Professional 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 Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). 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) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. 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. 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) Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 93187-A, 93188-A Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment 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 (Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. 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

Created: 2026-03-30