The Patient Aligned Care Team is a comprehensive team which delivers primary care to Veteran patients in a longitudinal rather than episodic fashion and which has as its focus: prevention; health promotion, coordination and chronic disease management & the Transition and Care Management (TCM) Program's Social Work Case Manager provides comprehensive social work service to Post 9/11 transitioning and established Servicemembers and Veterans (SM/Vs) and their families across the continuum of care. Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship. Non-citizens may only be appointed when it is not possible to recruit