Social Worker

About the role

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.

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, caregivers, and healthcare professionals.
• Strong communication and collaboration skills, with the ability to effectively engage participants, caregivers, community resources, and cross-functional teams to deliver coordinated, participant-centered care.
• Strong organizational skills with the ability to manage multiple priorities while maintaining attention to detail and ensuring timely follow-through.
• Demonstrated ability to work independently while collaborating across interdisciplinary teams to achieve shared outcomes.
• Experience using Electronic Medical Records (EMRs) and the ability to quickly learn organizational documentation systems.
• Proof of a valid driver's license, reliable personal transportation, and automobile insurance that meets applicable state requirements, with the ability to travel throughout the service area.
• Active CPR/BLS certification or the ability to obtain certification within 30 days of hire.
• Meets all applicable participant-facing health requirements, including TB screening and required immunizations.
• Aligns with our purpose and our values, and is excited about living those out in daily practice
• Ability to thrive in a fast-paced, evolving environment with comfort navigating ambiguity, adapting quickly, and contributing to continuous improvement
• Strong learning and growth mindset, including seeking feedback, engaging in healthy debate and using data and curiosity to inform decisions.
• Acts with integrity and ownership, considering the broader organizational impact, doing the right thing, and following through to deliver results.

Nice to have

• Licensed Clinical Social Worker (LCSW) or eligibility for clinical licensure.
• Experience working within PACE, Medicare, Medicaid, managed care, or other value-based healthcare environments.
• Experience supporting participants with behavioral health, substance use, or other complex psychosocial needs.
• Bilingual: Spanish, Mandarin, or Cantonese.

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 - $78,000. This position is also eligible for a target annual bonus of 5% 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.

Vaccination Policy, including COVID-19

To help maintain a safe environment for our participants and team members, Habitat Health maintains vaccination and infection control policies applicable to certain roles and work locations. For COVID-19 and influenza, team members who are working in a participant care setting are required to provide either proof of vaccination or a signed declination form and comply with applicable masking requirements while in a care setting to the extent permitted by law in the applicable jurisdiction.

As a condition of employment, team members are expected to comply with all applicable infection control protocols, personal protective equipment (PPE) requirements, and vaccination requirements associated with their role and work location, and to the extent required by law and as permitted in the applicable jurisdiction.