The VA Portland Health Care System (VAPORHCS) 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. As part of the Rural PACT Initiative, the Senior Social Worker has the following areas of assignment: (1) ensuring the PACT model of social work care is delivered to assigned Veterans at the remote site of care, (2) utilizing the VSSC Unassigned Patient List to provide proactive outreach and case management services to facilitate Veteran enrollment for care and assignment to a PACT, (3) partnering with the Community Care Nurse Liaison Program to facilitate Veteran discharge from non-VA hospitals, (4) utilizing the VSSC Care Assessment Need (CAN) Score report to provide proactive outreach and case management services for Veterans at risk of hospitalization or death, and utilizing the VSSC High Need/High Risk Veterans & HPBC Partnerships Expansion report to provide proactive outreach and case management services to facilitate Veteran enrollment with HBPC or other non-institutional care services. These program teams are located at various sites in VISN 20 and are closely associated with VAPORHCS Business Office, Primary Care, and Rehabilitation & Long Term Care. These multidisciplinary teams and clinics include medical, nursing, behavioral, and administrative staff. Rural PACT Initiative social work services include primary and secondary health care services, to include, but not limited to, psychosocial screening and assessment, psychosocial treatment and intervention, specialized case management and care coordination, discharge and/or after-care planning, health education and advanced health care planning, supportive counseling and caregiver support, interdisciplinary collaboration, coordination, and consultation, and administrative and professional duties. Rural PACT Initiative Senior Social Workers work closely with other members of the assigned highly rural CBOC and with members of affiliated program offices associated with the Rural PACT Initiative program goals. Major duties will include but will not be limited to: The incumbent completes behavioral health clinical reminders for patients in assigned specialty clinics. The incumbent conducts clinical reminders during clinic visits and, as needed, by telephone as clinic visit follow-ups. The incumbent may also provide clinical support to non-assigned specialty clinics for behavioral health clinical reminders. The social worker uses advanced knowledge and mastery of theories and modalities required for the treatment of complex medical, behavioral, and psychosocial health care needs of Veterans in the above assigned clinics and specialty care programs. The social worker works closely with Veterans to identify and support their preferences in care and personal treatment goals, and offers resources and support tailored to the uniquely expressed needs and desires of the Veteran. The social worker serves as the key link for education and psychosocial support for Veterans, families, and caregivers across the continuum of care. The incumbent evaluates progress towards treatment goals and proposes changes in the treatment plan, as appropriate. The incumbent monitors Veteran's progress, maintains comprehensive documentation, ensures diagnosis and treatment of clinical disorders, shows discretion in decisions to adjust treatment, and makes recommendations for care changes to the interdisciplinary treatment plan. Position is 100% virtual, with the requirement to attend in-person trainings, meetings, and re-occurring on-site duties as needed. Work Schedule: Monday - Friday, 7:30 am to 4pm PST or 8am to 4:30pm PST. Telework: Available * Virtual: This is a virtual position.* * This position is virtual, but the selected candidate will be required to live within the catchment area for which they are applying. Position Title/Functional Statement #:Senior Social Worker, Rural Patient Aligned Care Team (PACT)/PD000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required