This position is located within VA Altoona and it's affiliated CBOC's. The Senior Social Worker performs duties within a dual capacity in the Community Nursing Home (CNH) and Home Based Primary Care (HBPC). Incumbent is responsible for providing administrative oversight and providing clinical case management throughout the catchment areas.
Summary
This position is located within VA Altoona and it's affiliated CBOC's. The Senior Social Worker performs duties within a dual capacity in the Community Nursing Home (CNH) and Home Based Primary Care (HBPC). Incumbent is responsible for providing administrative oversight and providing clinical case management throughout the catchment areas.
The CNH Coordinator will work collaboratively with CNH staff, JEVZ staff, and nursing home staff; be knowledgeable of VA and community resources; provide information/education to nursing home staff, JEVZ staff, Veterans and caregivers; and serve as a liaison between the nursing home and primary care team to assist with coordination of care needs. The CNH Coordinator will also be responsible for Contracting Officer's Representative (COR) duties, acting as a liaison and maintaining COR level 2 certification.
The CNH Coordinator will conduct initial and annual CNH facility assessments, completing required forms and ensuring storage of forms locally and nationally; attend monthly meetings with VISN REC-ICC Lead; ensure all CNH documentation is accessible and following national standards. The CNH Coordinator will lead the CNH Review Team and act as facilitator for the CNH Oversight Committee; be responsible for writing Issue Briefs and Heads Up Notifications; and track and report program data and outcomes.
The CNH Coordinator may complete on-site visits to the nursing homes for clinical assessment; participate in interdisciplinary care plan meetings facilitated by the nursing homes; facilitate referrals and consults and ensure that the Veteran's identifying concern is addressed and concluded by the receiving consultant; and complete discharge planning with nursing home staff.
The HBPC Social Worker will complete comprehensive initial clinical assessments; complete follow-up assessments at a minimum annually and when clinically indicated; identify psychosocial issues impacting the Veteran/caregiver ability to achieve optimal outcomes; implement interventions; and provide case management.
The HBPC Social Worker will develop a psychosocial plan of care which may include individual/family counseling, grief and bereavement counseling, advance care planning, pain interventions, stress management, caregiver respite, and psycho-education; facilitate access to and maximize VA and community resources and services; interact, coordinate and advocate for the Veteran/caregiver; provide education to the Veteran/caregiver; assess and support the caregiver's capability to continue to provide care; complete screenings/reminders; and assist with discharge planning.
The HBPC Social Worker will keep the HBPC team informed of available resources and supports; participate in the development of the individual plan of care; participate in the development and implementation of the HBPC's process for continuous improvement; participate in interdisciplinary care meetings; document patient care accurately and timely; participate in the determination or the appropriateness of Veterans admission to or discharge from HBPC; and participate in the development of a local SOP's and have knowledge of The Joint Commission (TJC) to include TJC Accreditation Manual for Home Care. Performs other duties as required.
Work Schedule: 8:00am - 4:30pm, Monday - Friday Telework: Not available Virtual: This is not a virtual position. Functional Statement #: 000000 / Senior Social Worker Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized
Selective Service Registration is required for males born after 12/31/1959.
Must be proficient in written and spoken English.
You may be required to serve a trial period.
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 dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
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/.
Grade Determinations: Senior Social Worker, GS-12
Experience/Education: The candidate must have at least two years of experience post advanced practice clinical licensure and should be in a specialized area of social work practice of which, one year must be equivalent to the GS-11 grade level. Senior social workers have experience that demonstrates possession of advanced practice skills and judgment. Senior social workers are experts in their specialized area of practice. Senior social workers may have certification or other post-masters training from a nationally recognized professional organization or university that includes a defined curriculum/course of study and internship or equivalent supervised professional experience in a specialty.
Licensure/Certification: Senior social workers must be licensed or certified by a state at the advanced practice level which included an advanced generalist or clinical examination, unless they are grandfathered by the state in which they are licensed to practice at the advanced practice level (except for licenses issued in California, which administers its own clinical examination for advanced practice) and they must be able to provide supervision for licensure.
Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, candidates must demonstrate all of the following KSAs:
Skill in a range of specialized interventions and treatment modalities used in specialty treatment programs or with special patient populations. This includes individual, group, and/or family counseling or psychotherapy and advanced level psychosocial and/or case management.
Ability to incorporate complex multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice.
Knowledge in developing and implementing methods for measuring effectiveness of social work practice and services in the specialty area, utilizing outcome evaluations to improve treatment services and to design system changes.
Ability to provide specialized consultation to colleagues and students on the psychosocial treatment of patients in the service delivery area, as well as role modeling effective social work practice skills.
Ability to expand clinical knowledge in the social work profession, and to write policies, procedures, and/or practice guidelines pertaining to the service delivery area.
The full performance level of this vacancy is GS-12. The actual grade at which an applicant may be selected for this vacancy is GS-12.
Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Services.
Education
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/.
Additional information
Grandfathering Provision: The following is the standard grandfathering policy for all title 38 hybrid qualification standards. Please carefully review the qualification standard to determine the specific education and/or licensure/certification/registration requirements that apply to this occupation.
All persons employed in VHA in this occupation on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series and grade held, including positive education and licensure or certification that are part of the basic requirements of the occupation. For employees who do not meet all of the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply.
Such employees in an occupation that requires a licensure or certification, may be reassigned, promoted up to and including the full performance (journey) level, or changed to lower grade within the occupation, but may not be promoted beyond the journey level or placed in supervisory or managerial positions.
Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended or be reappointed, on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all of the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation.
If an employee who was retained in an occupation listed in 38 U.S.C. ยง 7401(3) under this provision leaves that occupation, the employee loses protected status and must meet the full VA qualification standard requirements in effect at the time of reentry to the occupation.
During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.
This job opportunity announcement may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.
Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
How you will be evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
To apply for this position, you must provide a complete Application Package which includes:
Resume
SF-50/ Notification of Personnel Action
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.
Cover Letter
License
Resume
SF-50/ Notification of Personnel Action
Transcript
Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
Veterans' preference does not apply for internal or other current permanent Federal agency employees.
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
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 09/25/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12802899.
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.
James E Van Zandt VA Medical Center
2907 Pleasant Valley Boulevard
Altoona, PA 16602
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
To apply for this position, you must provide a complete Application Package which includes:
Resume
SF-50/ Notification of Personnel Action
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.
Cover Letter
License
Resume
SF-50/ Notification of Personnel Action
Transcript
Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
Veterans' preference does not apply for internal or other current permanent Federal agency employees.
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
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 09/25/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12802899.
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.
James E Van Zandt VA Medical Center
2907 Pleasant Valley Boulevard
Altoona, PA 16602
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
Fair and transparent
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
