LCSW Per diem, Pre-Enrollment (PACE)

About the role

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.

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

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
• Familiarity with conservatorship and guardianship processes in California

Pay

The anticipated base salary range for this position is $40.00 - $46.00 per hour. 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.

Benefits

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.