Social Worker (MSW) – Elder Care

About the role

Habitat Health is seeking a Master‑level Social Worker (MSW) to join its interdisciplinary team delivering PACE services to older adults in Sacramento. The role supports participants’ psychosocial needs, coordinates care transitions, and contributes to a welcoming center environment.

Key responsibilities

• Conduct comprehensive social work assessments to identify participants’ needs, preferences, and goals.
• Develop, deliver, and document individualized interventions such as resource linkage, counseling, and case management.
• Collaborate with primary care providers, nurses, and other team members to ensure smooth transitions across settings (hospital, skilled nursing, home).
• Facilitate and lead care conference meetings with participants, families, and support networks.
• Provide discharge planning and support when participants leave the program.
• Contribute to a positive center culture, seek feedback, and help improve clinical outcomes.
• Uphold Habitat Health’s values and adhere to assessment and care‑plan compliance.

Required profile

• Master of Social Work (MSW) degree.
• Experience working with older adult populations, preferably in a PACE or similar integrated care setting.
• Strong ability to conduct assessments, case management, and group counseling.
• Excellent communication and teamwork skills to function within an interdisciplinary team.
• Commitment to person‑centered care and cultural humility.

Required skills