Social Worker (Home Based Primary Care)

Social Worker (Home Based Primary Care)

Department: Department of Veterans Affairs

Location(s): Salem, Oregon

Salary Range: $75125 - $118170 Per Year

Job Summary: VA Portland Health Care System is a Complexity Level 1a Facility and provides extensive primary, secondary, tertiary, and quaternary care in outpatient, inpatient, residential, and community settings. VAPORHCS is a multi-site medical system that includes a major medical facility in Portland, Oregon, outpatient and residential facilities in Vancouver, Washington, and 10 Community Based Outpatient Clinics.

Major Duties:

• VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU The duties of this position include but are not limited to the following: The Home Based Primary Care (HBPC) Social Worker functions as a member of a multidisciplinary team, providing comprehensive, longitudinal, interdisciplinary, primary care in the homes of Veterans with serious medical, psychosocial, and behavioral conditions for whom routine clinic-based care is not effective or may not be possible. The team focuses on maximizing or maintaining Veteran function, minimizing institutionalization, and maintaining Veteran quality of life. The HBPC social worker independently assesses, develops, and implements treatment for individuals with complex chronic diseases that worsen over time. The HBPC social worker manages their case load and provides intensive case management and caregiver support. HBPC social workers collaborate with community partners and other professional agencies in care coordination and mobilization of tailored services for the Veteran or caregiver. These services are varied, flexing to address complex medical, psychosocial, mental health, rehabilitative, behavioral, and/or palliative care needs. The social worker is assigned to HBPC, a service within the Rehabilitation & Long-Term Care division. The social worker's physical location will be Bend, Salem, Vancouver, or Portland. Patient assignments are made by the HBPC team manager or HBPC leadership. The social worker provides social work services to Veterans in their homes and, when appropriate, using telephone or video technology. The employee operates a government vehicle in the performance of their duties, and, subsequently, must maintain medical clearance from the employee health department, have a valid state driver's license, and provide proof of insurability. The HBPC social worker uses independent social work practice and intervention to treat the complex HBPC patient population. These patients have complex chronic diseases that worsen over time. The HBPC social worker's scope and function include the following: a. Psychosocial Screening and Assessment. The social worker uses knowledge and theories of mental health and aging to independently perform comprehensive initial and follow-up assessments to meet the psychosocial needs of the patient and their support systems. Assessments include physical limitations, psychological/psychiatric needs, cognitive deficits, social and environmental milieus, based approach focused on the Veteran's goals. The social worker independently uses evidence-based screening tools and assessments. b. Psychosocial Treatment Planning and Goal Setting. The social worker develops the psychosocial plan of care, following advanced assessment and screening, to improve the patient's ability to achieve optimal psychosocial functioning. The social worker includes the Veteran's goals of care in the plan of care. The patient-centered, plan of care may include individual and family counseling, long-term and advance care planning, non-pharmacological pain intervention, stress management, caregiver support, psycho-educational programming, and grief and bereavement counseling. The social worker partners with the interdisciplinary team to enhance the Veteran's psychosocial treatment plan, experience, and progress toward treatment goals. c. Crisis Intervention. The social worker is independently responsible for crisis intervention and/or suicide prevention in home environments. The social worker functions without additional staff support or supervision in patient homes. The social worker performs rapid assessments and develops crisis management plans. Crises may include but are not limited to housing, finances, psychiatric relapse, suicidality, or violence. The social worker will assess for suicidality and self-harm, perform appropriate interventions, and create a safety plan for the Veteran. When responding to suicidality or a psychiatric emergency, the social worker will collaborate with first responders to ensure optimal home and prehospital care. The social worker will assist with admission to inpatient programs as needed. The HBPC social worker follows applicable protocols when responding to medical or psychological emergencies. Work Schedule: Monday-Friday, 7:30am-4:00pm or 8:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized

Qualifications: 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. 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/Accreditation 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/. (1) Exception. VHA may waive the licensure or certification requirement for persons who are otherwise qualified, pending completion of state prerequisites for licensure/certification examinations. This exception only applies at the GS-9 grade level. For the GS-11 grade level and above, the candidate must be licensed or certified. At the time of appointment, the supervisor, chief social work or social work executive will provide the unlicensed/uncertified social worker with the written requirements for licensure or certification, including the time by which the license or certification must be obtained and the consequences for not becoming licensed or certified by the deadline. (a) For appointments at the GS-9 grade level, VHA social workers who are not licensed or certified at the time of appointment must become licensed or certified at the independent, master's level within three years of their appointment as a social worker. Most states require two years of post-MSW experience as a prerequisite to taking the licensure/certification exam, and VHA gives social workers one additional year to pass the licensure/certification exam. In states such as California, Washington, and others where the prerequisites for licensure exceed two years, social workers must become licensed at the independent, master's level within one year of meeting the full state prerequisites for licensure. (b) A social worker who does not yet have a license that allows independent practice must be supervised by a licensed independent practitioner of the same discipline who is a VA staff member and who has access to the electronic health record. (c) Different states have different levels of licensure or certification, making it difficult for VHA staff to determine the independent practice level. Each state, Puerto Rico, and the District of Columbia completed surveys identifying the level of licensure or certification allowing independent practice. Copies of the surveys are on file in the VHA Office of Care Management and Social Work Services, and a summary spreadsheet of the levels of licensure or certification is available to social work professional standards board members for purposes of determining whether the social worker's level of licensure or certification meets the VHA qualification standards. All states except California use a series of licensure exams administered by the ASWB. Grandfathering Provision-May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). Grade Determinations: Social Worker, GS-9 (1) Experience, Education, and Licensure. None beyond the basic requirements. (2) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to utilize counseling skills when working with Veterans and family members. (b) Ability to assess the psychosocial functioning and needs of Veterans and their family members, and to formulate and implement a treatment plan, identifying the Veterans problems, strengths, weaknesses, coping skills, and assistance needed. (c) Ability to implement treatment modalities in working with individuals, families, and groups to achieve treatment goals. This requires judgment and skill in utilizing supportive, problem solving, or crisis intervention techniques. (d) Ability to establish and maintain effective working relationships and communicate with clients, staff, and representatives of community agencies. (e) Fundamental knowledge of medical and mental health diagnoses, disabilities, and treatment procedures. This includes acute, chronic, and traumatic illnesses/injuries; common medications and their effects/side effects; and medical terminology. Social Worker, GS-11 (1) 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 (2) 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. (3) 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, educational, and other 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. Driving is required for this position. Must have valid driver's license and proof of insurance Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-11. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9 to GS-11. Physical Requirements: Light lifting and carrying (under 15 lbs); use of fingers, both hands required; walking & standing (1 hour); both hands required; Operation of motor vehicle; ability for rapid mental & muscular coordination simultaneously; ability to distinguish basic colors; hearing (aid permitted). Environmental factors include exposure to: excessive heat/cold, dust/fumes, working alone & with others, working around moving vehicles, overhead light, ambient noise, smells from being in close proximity with others (including soap, shampoo, perfume, food and/or lingering tobacco smoke from smokers).

How to Apply: All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 03/24/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12910674. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

Application Deadline: 2026-03-24