PACE Pre-Enrollment Master of Social Work

About this role

Habitat Health empowers older adults to experience more good days in their homes and communities. Through the Program of All-Inclusive Care for the Elderly (PACE), we provide comprehensive medical care along with support for daily needs such as meals, transportation, and in ‑ home assistance. We deliver coordinated clinical and social care in our centers and directly in participants’ homes, creating a fully integrated experience that brings peace of mind and a true sense of belonging. As we expand our scalable, affordable PACE model to meet the growing and complex needs of aging populations, our mission ‑ driven care teams continue to help participants live well on their own terms.

Habitat Health is supported by leading healthcare organizations and investors including New Enterprise Associates, Kaiser Permanente, and Town Hall Ventures. We are entering a period of significant growth and are looking for exceptional teammates to help us scale a better model of care for older adults. To learn more, visit www.habitathealth.com.

Role Scope :

We are seeking a dedicated and experienced Master of Social Work (MSW) to join our Pre-Enrollment Clinical Team as a full-time MSW (Monday–Friday, 8:00 AM–5:00 PM). This is a remote position based in California. In this role, you will conduct comprehensive psychosocial assessments each day, with approximately 95% of assessments conducted virtually via telehealth. When high-risk cases are identified requiring a more comprehensive in-person evaluation, you may be asked to travel to the applicant's home or PACE center site (SAC or SLA). You will ensure applicants meet both clinical criteria and Health and Safety requirements for community-based care, working collaboratively with our interdisciplinary enrollment team to facilitate safe transitions into our program while advocating for older adults' autonomy and dignity.

• Conduct comprehensive psychosocial assessments for prospective PACE participants during the pre-enrollment process, evaluating cognitive, emotional, behavioral, and social functioning

• Perform specialized assessments for behavioral health and psychosocial referrals, reviewing complex cases identified by the Enrollment team.

• Evaluate applicants' capacity for informed consent and decision-making regarding PACE enrollment and care planning.

• Assess whether prospective participants with mental health conditions, cognitive impairment, or behavioral challenges can be safely managed in community-based settings per Health and Safety regulations

• Complete detailed social histories, including family dynamics, support systems, housing stability, financial resources, and cultural considerations

• Administer standardized assessment tools (PHQ-9, GAD-7, MMSE, MoCA, GDS, ADL/IADL scales) and interpret results within the context of geriatric best practices

• Collaborate with the interdisciplinary team to develop preliminary care plans and identify immediate service needs prior to enrollment.

• Provide crisis intervention and safety planning when indicated during the assessment process.

• Complete same-day or next-day Epic documentation for all assessments — virtual and in-person — in accordance with PACE regulatory requirements, Title 22 standards, and organizational policies

• Serve as a liaison between prospective participants, families, and community resources during the transition to PACE enrollment

Qualifications:

• Master’s degree in Social Work (MSW) required

• Minimum of 1 year of post-graduate clinical experience, with at least 2 years working with older adults and geriatric populations

• Strong knowledge of geriatric mental health, including dementia care, depression, anxiety disorders, and age-related psychological changes

• Experience conducting comprehensive psychosocial assessments and biopsychosocial evaluations for complex older adults

• Experience with standardized geriatric assessment tools (BIMS, PHQ-9, MoCA, MMSE) and interpreting results for eligibility determination

• Understanding of California’s social work scope of practice and MSW-level competencies

• Knowledge of capacity assessment principles and ability to evaluate decision-making abilities in older adults with cognitive impairment

• Experience with crisis intervention, safety planning, and risk assessment in community-based settings

• Excellent clinical documentation skills that meet regulatory standards and demonstrate medical necessity

• Proficiency with Epic electronic health record system or similar EHR platforms

• Experience working in interdisciplinary team environments and collaborative care models

• Understanding of CMS and DHCS regulations related to PACE enrollment criteria and Health and Safety requirements

• Knowledge of Medicare and Medicaid eligibility requirements and benefits

• Understanding of Nursing Facility Level of Care (NFLOC) criteria and ability to document how applicants meet these requirements

• Knowledge of home safety evaluation and ability to assess if an applicant can live safely at home with PACE services

• Reliable personal transportation required for occasional in-person visits; must be able to travel to applicant homes or PACE center sites (SAC or SLA) when high-risk cases require in-person evaluation

Nice to have:

• Previous experience in PACE, CCRCs, or similar programs serving older adults with complex needs

• Familiarity with California Title 22 PACE regulations and enrollment processes

• Experience evaluating whether individuals with behavioral health conditions or cognitive impairment can be safely managed in community settings

• Knowledge of community-based long-term care services and supports (IHSS, CBAS, etc.)

• Experience with telehealth for social work assessments and interventions

• Training in trauma-informed care approaches for older adults

• Experience working with diverse populations and cultural competency in serving ethnic minority communities

• Bilingual in Spanish and English — pre

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