Social Worker (MSW)

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 looking for a dynamic, service-oriented Social Worker to support elderly persons in their journey. Under the supervision of our Social Services Manager, the MSW is a critical member of the IDT to ensure compliance with assessments and care plans. Core Responsibilities & Expectations for the Role Contribute to a center experience that Participants want to spend time in, a team culture that cares and creates joy, and an environment where all participants and team members belong. Continue to raise the bar. Constructively seek and share feedback and help us implement changes in order to improve clinical outcomes and experience for participants. Exhibit and honor Habitat’s values. Collaborate as part of the Interdisciplinary Team (IDT) to optimize health status and quality of life of the participants as part of the care plan. Conduct social work assessments to determine psychosocial needs, preferences and goals of the participants Deliver and document social work interventions as agreed upon in the participants’ care plan including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual as well as group counseling and case management. Collaborate with primary care providers and other members of the care team to guide smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home, etc.) Initiate, coordinate and facilitate care conference meetings to ensure the highest level of care coordination among other care team members, participants, and other people within the participants’ support network (family, informal caregivers, etc.) Provide discharge planning when participants disenroll from the program Performs related duties as assigned. Required Qualifications: Master’s degree in Social Work (MSW). A minimum of 1 year experience working with the frail or elderly. Previous experience coordinating and facilitating care conference meetings. Proof of medical clearance for communicable diseases, including a TB test. Proof of all immunizations are up to date. Proof of current CPR/BLS certification required or requirement to obtain within 30 days of employment. Proof of valid CA driver’s license, personal transportation, good driving record and auto insurance as required by State law. Preferred Qualifications: Bilingual: Spanish/English preferred. Previous experience assisting patients/participants with behavioral health and substance abuse issues. Experience working with PACE/ADHC/CBAS programs A state issued driver’s license, personal transportation, and auto insurance as required by law. Location: Sacramento, CA (Onsite) Compensation: The anticipated base salary range for this position is$74,000 - $84,000 . This position 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 quali…