LCSW Per diem, Pre-Enrollment (PACE)

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 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 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   Familia