Outpatient Behavioral Health Interdisciplinary Program (BHIP) team-based care provides Veteran-centered, recovery-oriented, and evidence-based care. The incumbent in this position functions as a Care Coordinator for Veterans on a BHIP team and is responsible for coordination and continuity of care for Veterans receiving services throughout the Behavioral Health Service Line. 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/. 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-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. OR, 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. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, candidates must demonstrate all of the following KSAs: Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. 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. 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. 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. 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. References: VA HANDBOOK 5005, PART II, APPENDIX G39 The full performance level of this vacancy is GS-11. The actual grade at which an applicant may be selected for this vacancy is GS-11. Physical Requirements: Must be able to walk/stand for at least 8 hours a day; ability for rapid mental and muscular coordination simultaneously; far vision correctable in one eye to 20/20 and to 20/40 in the other; ability to distinguish basic colors; hearing (aid permitted); clear speech; will be outside and inside; possible excessive noise, intermittent; work closely with others. Must be able to pass drivers physical. ["The candidate is a Social Worker assigned to a BHIP team at the VA Pittsburgh Healthcare System. The incumbent is responsible for providing care coordination services (including but not limited to biopsychosocial assessment, walk-in/crisis services, education, provision of self-management resources) and other care coordination tasks as needed for Veterans receiving services in BHIP. Care coordination (including care management and/or case management) includes determining and monitoring care coordination needs over time, providing care coordination, and facilitating follow-up and outreach as needed to promote proactive, personalized care and care continuity. Major duties include, but may not be limited to: The incumbent will provide a full range of services within commonly accepted standards of practice and prioritizes care coordination activities as the primary job function [e.g., needs assessment, chart reviews, care, or case management (as needed), discharge planning, outreach, etc.] and other services as appropriate. The incumbent will provide care coordination (including care management or case management) to Veterans and families, as needed, throughout the continuum of care. This includes communication within and across care lines to facilitate continuity of care for Veterans. The incumbent will conduct biopsychosocial assessments to determine care coordination and treatment needs of Veterans. The incumbent will provide consultation/education to Veterans and families on VA resources (including self-management tools), community resources, Advance Directives and VA benefits. The incumbent will be an active participant in the treatment planning process with other disciplines. The incumbent will participate in discharge planning with other disciplines and will be responsible for ensuring that discharge plans are executed in a manner that is timely and appropriate to promote care continuity. The incumbent will act as a clinical resource/point-of-contact to Veterans and other team/staff members. The incumbent will act as liaison between VA and community resources, to include education and bidirectional communication that promotes seamless care. Though not a core function of this position, there may be times when the incumbent may provide individual, family and group counseling as appropriate. The incumbent will provide wellness/prevention education and may facilitate patient/family educational/bridging supportive sessions as appropriate. The incumbent will document interventions and activities in patient's electronic health record and ensure appropriate hand-off communication and documentation when transferring patient care. Supports the mission, policies, and procedures of the Department of Veterans Affairs, the Veterans Health Administration (VHA), the appropriate Veterans Integrated Service Network (VISN), and the facility. Serves on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor and Social Work Program Manager, and/or Designee. Informs the immediate supervisor of problems and recommended solutions to problems encountered in the incumbent's area of responsibility. Is responsible for maintaining compliance with Pennsylvania Social Work Licensure Requirements and completion of VA social Work Requirements for competence. Provides assistance with the orientation for new social workers working within the Community Based Care Service Line, and, if interested, to serve as a preceptor for social work interns/students. May perform other duties as directed. Work Schedule: 8:00am - 4:30pm, Monday - Friday\nTelework: May be authorized for highly qualified candidates\nVirtual: This is not a virtual position.\nFunctional Statement #: Social Worker (BHIP) / 000000\nRelocation/Recruitment Incentives: Not authorized\nPermanent Change of Station (PCS): Not authorized\nFinancial Disclosure Report: Not required"]