LCSW Per diem, Pre-Enrollment (PACE)

At Habitat Health, we envision a world where older adults experience an independent and joyful aging journey in the comfort of their homes, enabled by access to comprehensive health care. Habitat Health provides personalized, coordinated clinical and social care as well as health plan coverage through the Program of All-Inclusive Care for the Elderly (“PACE”) in collaboration with our leading healthcare partners, including Kaiser Permanente. Habitat Health offers a fully integrated experience that brings more good days and a sense of belonging to participants and their caregivers. We build engaged, fulfilled care teams to deliver personalized care in our centers and in the home. And we support our partners with scalable solutions to meet the health care needs and costs of aging populations. Habitat Health is growing, and we’re looking for new team members who wish to join our mission of redefining aging in place. To learn more, visit https://www.habitathealth.com . Role Scope : We are seeking a dedicated and experienced Licensed Clinical Social Worker to serve as our Per Diem Pre-Enrollment LCSW for our PACE program. In this per diem capacity, you will conduct comprehensive psychosocial assessments and eligibility evaluations for prospective PACE participants on an as-needed basis, ensuring they meet both clinical criteria and Health and Safety requirements for community-based care. You will work 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. Document all assessments, recommendations, and eligibility determinations 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: Current, unrestricted Licensed Clinical Social Worker (LCSW) license in California (BBS License required) Master's degree in Social Work (MSW) Minimum of 1 years of post-licensure 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 LCSW scope of practice as defined in Business & Professions Code Sections 4996-4999.129 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 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 skills (particularly Spanish/English) Experience with advance care planning and end-of-life care coordination Knowledge of elder abuse identification and mandatory reporting requirements Experience working with adults with developmental disabilities who are aging Familiarity with conservatorship and guardianship processes in California Compensation: We take into account an individual’s qualifications, skillset, and experience in determining final compensation. As a per diem position, this role is compensated on an hourly basis and is not eligible for company benefits such as medical/dental/vision insurance, paid time off, or 401(k) savings. The expected hourly rate for this position is $40 - $46 hourly. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. Vaccination Policy, including COVID-19 At Habitat Health, we aim to provide safe and high-quality care to our participants. To achieve this, please note that we have vaccination policies to keep both our team members and participants safe. For covid and flu, we require either proof of vaccination or declination form and required masking while in participant locations as a safe as an essential requirement of this role. Requests for reasonable accommodations due to an applicant’s disability or sincerely held religious beliefs will be considered and may be granted based upon review. We also require that team members adhere to all infection control, PPE standards and vaccination requirements related to specific roles and locations as a condition of employment. Our Commitment to Diversity, Equity, and Inclusion : Habitat Health is an Equal Opportunity employer and is committed to creating a diverse and inclusive workplace. Habitat Health applicants are considered solely based on their qualifications, without regard to race, color, religion, creed, sex, gender (including pregnancy, childbirth, breastfeeding or related medical conditions), gender identity, gender expression, sexual orientation, marital status, military or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), or other status protected by applicable law. Habitat Health is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Habitat Health will take steps to provide people with disabilities and sincerely held religious beliefs with reasonable accommodations in accordance with applicable law. Accordingly, if you require a reasonable accommodation to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact us at [email protected]. Beware of Scams and Fraud Please ensure your application is being submitted through a Habitat Health sponsored site only. Our emails will come from @habitathealth.com email addresses. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option: https://reportfraud.ftc.gov/#/.