Part-Time Social Worker – Elder Care

About the role

Habitat Health is seeking a part‑time Social Worker to join its interdisciplinary team in Sacramento, CA. The role supports older adults enrolled in the Program of All‑Inclusive Care for the Elderly (PACE), providing psychosocial assessments, care coordination, and counseling. The Social Worker reports to the Social Services Manager and works onsite with participants, families, and the care team.

Key responsibilities

• Contribute to a welcoming center environment and team culture.
• Seek and share feedback to improve clinical outcomes and participant experience.
• Uphold Habitat’s values in daily interactions.
• Collaborate with the interdisciplinary team to optimize participants’ health and quality of life.
• Conduct social work assessments to identify psychosocial needs, preferences, and goals.
• Deliver and document interventions, including resource coordination, care transitions, individual and group counseling, and case management.
• Work with primary care providers and care team members to ensure smooth transitions across settings such as hospitals, skilled nursing facilities, and homes.
• Initiate, coordinate, and facilitate care conference meetings with participants, families, and support networks.
• Provide discharge planning when participants disenroll from the program.

Required profile

• Master’s degree in Social Work (MSW).
• Ability to work part‑time onsite in Sacramento, CA.
• Works under the supervision of the Social Services Manager as a member of the IDT.
• Commitment to serving older adults in a PACE setting.

Required skills