PACE Pre- Enrollment LCSW Per diem

Habitat Health•Alameda, CA

5d•$40 - $46

About The Position

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.

Requirements

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 Haves

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

Responsibilities

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