LCSW, Pre-Enrollment – PACE

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Logo of Habitat Health

Habitat Health

1 - 10 employees

Founded 2023

⚕️ Healthcare Insurance

🧘 Wellness

🌍 Social Impact

Healthcare Insurance • Wellness • Social Impact

Habitat Health is a healthcare organization focused on empowering older adults to live independently in their homes and communities. Through the Program of All-Inclusive Care for the Elderly (PACE), Habitat Health provides comprehensive health insurance coverage and medical and social care services. Their services include transportation, personal care, 24/7 care access, physical therapy, nutrition support, pharmacy and prescriptions, medical care, and social services. Operating in partnership with notable healthcare providers such as Kaiser Permanente, Habitat Health is committed to creating a supportive and inclusive environment for both participants and staff, ensuring the provision of personalized, coordinated care. Founded in 2023, the company aims to enhance the lives of older adults covered by Medicare or Medicaid.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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 • company paid holidays

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