PACE Pre-Enrollment Master of Social Work

Job Description

Job Description

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

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 — preferred; Spanish-speaking candidates strongly encouraged to apply

• 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

Essential Functions & Physical Requirements

The following statements describe the general nature of work and physical expectations common across roles at Habitat Health. Specific responsibilities may vary by position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Team members in this role may be expected to

• Work in healthcare, administrative, community, or remote environments, depending on role needs.

• Communicate effectively with participants, caregivers, team members, and other stakeholders in person, by phone, and through electronic systems.

• Remain stationary and/or move about for extended periods, consistent with job duties.

• Operate standard office equipment and/or clinical tools (e.g., computers, phones, medical devices, documentation systems).

• Travel between work sites or community locations as needed.

• Follow safety procedures, infection control protocols, and use personal protective equipment (PPE) when required.

• Perform tasks that may involve bending, reaching, lifting, or assisting participants, depending on role responsibilities.

• Lift, carry, push, or pull supplies, equipment, or materials typically up to 25–50 pounds, with assistance or mechanical aids, depending on job duties and role responsibilities.

Compensation:

The anticipated base salary range for this position is $74,000 - $89,000. This position is also eligible for a target annual bonus and may be eligible for additional incentive compensation, as applicable.

The final compensation offered will be determined based on factors including, but not limited to, the candidate's qualifications, skills, experience, education, certifications, geographical location, and business needs.

In addition, this position is eligible for a comprehensive benefits package, including medical, dental, and vision insurance; paid parental leave, short- and long-term disability coverage; life insurance; flexible spending accounts; a 401(k) savings plan that includes a match; paid time off; and company paid holidays.

At-Will Employment

Employment with Habitat Health is at-will. This means that either the employee or the employer may terminate the employment relationship at any time, with or without cause, and with or without notice, subject to applicable law. Nothing in this job posting or any other company document is intended to create a contract of employment, express or implied, or to alter the at-will nature of employment.

Any written or oral statements to the contrary are not authorized unless made in writing and signed by an authorized representative of the Company.

Because this is a remote position, employment will be governed by the laws applicable to the employee's work location, and applicable legal requirements will be followed.

geographic location.

Vaccination Policy, including COVID-19

To help maintain a safe environment for our participants and team members, Habitat Health maintains vaccination and infection control policies applicable to certain roles and work locations. For COVID-19 and influenza, team members who are working in a participant care setting are required to provide either proof of vaccination or a signed declination form and comply with applicable masking requirements while in a care setting to the extent permitted by law in the applicable jurisdiction.

Habitat Health will consider requests for reasonable accommodation based on an applicant's disability, medical condition, or sincerely held religious belief, practice, or observance in accordance with applicable law.

As a condition of employment, team members are expected to comply with all applicable infection control protocols, personal protective equipment (PPE) requirements, and vaccination requirements associated with their role and work location, and to the extent required by law and as permitted in the applicable jurisdiction.

Our Commitment to Equal Opportunity and Inclusion

Habitat Health is an Equal Opportunity Employer committed to the principles of equal opportunity and inclusion. Employment decisions at Habitat Health are based on qualifications, merit, and business needs. We do not discriminate on the basis of race, color, religion, creed, sex, gender (including pregnancy, childbirth, breastfeeding, and related medical conditions), gender identity, gender expression, sexual orientation, marital status, registered domestic partner status, age, national origin, ancestry, citizenship, military or veteran status, physical or mental disability, medical condition, genetic information, reproductive health decision-making, or any other characteristic protected by applicable federal, state, or local law.

Habitat Health is committed to the full inclusion of all qualified individuals. Consistent with applicable law, we provide reasonable accommodations to qualified individuals with disabilities and to individuals with religious beliefs, practices, or observances that require accommodation.

If you require a reasonable accommodation to participate in the application or interview process, perform the essential functions of a position, or receive other employment benefits and privileges, please contact us at View email address on ziprecruiter.com.

We encourage individuals from all backgrounds to apply, even if their experience does not align perfectly with every qualification listed.

E-Verify Participation Notice

Habitat Health participates in E-Verify and will provide the federal government with information from your Form I-9 to confirm your authorization to work in the United States.

If E-Verify cannot confirm your authorization to work, Habitat Health will provide you with written instructions and an opportunity to contact the Department of Homeland Security (DHS) and/or the Social Security Administration (SSA) to resolve the issue before any adverse employment action is taken, including termination of employment.

E-Verify is used only after an applicant has accepted an offer of employment and completed the Form I-9 and to the extent permitted by applicable law.

Habitat Health complies with all federal and state employment eligibility verification requirements.

Beware of Scams and Fraud

Habitat Health is committed to protecting job seekers from recruitment scams. Please ensure that you submit applications only through Habitat Health's official careers website or authorized job boards.

Official communications from Habitat Health recruiters and team members will come from email addresses ending in @habitathealth.com. Habitat Health will never ask applicants to pay fees, purchase equipment, or provide sensitive financial information as part of the recruiting or hiring process.

If you receive suspicious communications claiming to represent Habitat Health, we encourage you to exercise caution and independently verify the communication before responding.

If you believe you have been the victim of a recruitment scam or fraudulent job posting, please report the incident to the Federal Trade Commission (FTC) through its fraud reporting website at reportfraud.ftc.gov.