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Social Worker-Home Based Primary Care (HBPC)

Veterans Health Administration · Posted 2 days ago

On-site Jackson, MI $70K – $110K Apply by Jul 17, 2026 Social Work ENFJESFJINFJINFP Healthcare
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About the Role

*Recruitment Incentive Authorized* The Clinical Social Worker provides direct services to adult and geriatric Veterans enrolled in the Home Based Primary Care (HBPC) Program/Specialty PACT with high quality case management, clinical treatment, advocacy, and to coordinate linkage with appropriate VA and community service providers / agencies as needed by the client. This is accomplished in collaboration with other members of the HBPC Team or interdisciplinary treatment teams as appropriate.

What You'll Do

  • Duties may include but are not limited to: Screening/Assessment - The Social Worker will develop an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others, whenever possible.
  • The goal of the assessment is to highlight the Veteran's strengths, limitations, and internal/external support and service needs to optimize the Veteran's functional status and safely maintain the Veteran in his/her home.
  • Within the HBPC Program the assessment will include a home visit.
  • The initial assessment and assessment updates will be completed as specified by the policy for the assigned work area.
  • Treatment Planning/Goal Setting - The Social Worker is responsible for contributing to the development of the treatment plan and setting achievable treatment goals with the Veteran, family members/significant others and other HBPC/Specialty PACT clinical staff.
  • Referral to service providers - Throughout the course of treatment, the Social Worker is the subject matter expert on VA and/or community resources.
  • The Social Worker will collaborate with other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements.
  • Resource Development - The Social Worker is responsible for developing a resource file of VA and community social service programs and enhancing the content to the benefit of Veterans.
  • Advocacy - The Social worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the Veteran and family members/significant others.
  • Crisis Intervention - The Social Worker is experienced in making rapid assessments and developing crisis management plans.
  • The Social Worker has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis.
  • Education/Health promotion and prevention - The Social Worker provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer Veterans and families/significant others to the appropriate interdisciplinary team member for identified health education needs.
  • Coordination of non-institutional and institutional services - The Social Worker is responsible for the coordination of the referrals of non-institutional services such as HBPC, CADHC, home hospice and skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members.
  • The Social Worker is also responsible for the coordination of the referrals of institutional placements in Adult Foster Homes, Medical Foster Homes, Assisted Living Programs, CNH, or VA CLC.

Requirements

  • 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
  • Effective May 7, 2025, driver's licenses or state-issued identification 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 "Required Documents" section of this announcement.
  • A current, valid state-issued Driver's License is required for this position.
  • NOTE: We cannot accept photographs, therefore; please do not submit a copy of your license with your application package.
  • If an interview is requested, you will be required to provide a copy of your current, valid state-issued Driver's License.

Personality Fit

This role is commonly a great fit for these MBTI types:

Job ID: 5834a187-4244-4798-a83b-a63d58e54cf7

Posted via USAJobs

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