PACE Pre-Enrollment Master of Social Work

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.