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 : The Master's Level Social Worker plays a key role in supporting the psychosocial health, well-being, and independence of Habitat Health participants through comprehensive assessment, counseling, care coordination, and resource navigation. As an integral member of the Interdisciplinary Team (IDT), this role partners with participants, caregivers, community resources, and healthcare professionals to address psychosocial needs, facilitate care transitions, advocate for participant goals, and deliver coordinated, participant-centered care that promotes quality of life.
Core Responsibilities & Expectations for the Role
Conducts comprehensive psychosocial assessments to identify participant strengths, needs, preferences, goals, and barriers that inform individualized care planning.
Develops, implements, and documents participant-centered social work interventions that promote psychosocial well-being, independence, and quality of life in alignment with the individualized care plan.
Partners with participants, caregivers, community resources, and the Interdisciplinary Team (IDT) to coordinate services, address psychosocial needs, and support integrated care delivery.
Facilitates care conferences and interdisciplinary discussions that promote collaborative decision-making, effective communication, and coordinated care planning.
Provides individual and group counseling, crisis intervention, case management, advocacy, and emotional support within the scope of practice to address participant and caregiver needs.
Coordinates care transitions by connecting participants and caregivers with appropriate resources, services, and support to promote continuity of care across healthcare settings.
Supports discharge planning and transition services for participants who disenroll from the PACE program, ensuring continuity of care and resource coordination.
Maintains accurate, timely, and compliant documentation within the Electronic Medical Record (EMR) and other organizational systems in accordance with organizational policies and regulatory requirements.
Contributes to continuous improvement by identifying opportunities to enhance participant experience, interdisciplinary collaboration, care coordination, and operational effectiveness.
Performs other related duties as assigned.
Required Qualifications:
Master's degree in Social Work (MSW) from an accredited program.
Minimum of two (2) years of experience working with older adults, frail elderly populations, or individuals with complex medical, behavioral health, or psychosocial needs.
Demonstrated ability to conduct comprehensive psychosocial assessments and develop participant-centered care plans.
Demonstrated ability to provide case management, counseling, crisis intervention, advocacy, and resource coordination within the scope of practice.
Experience coordinating care across interdisciplinary teams and facilitating care conferences with participants,…