Masters Level Social Worker

About my Place Health

my Place Health was founded in 2021 by mission-aligned healthcare leaders and organizations that are committed to drastically improving health outcomes, quality and experience for vulnerable older adults and frail seniors. We specialize in providing value-based, comprehensive care and coverage for older adults with significant needs so they can thrive in the homes they love and in the communities they cherish.

Our mission is simple: to enable older adults to live the independent lives they deserve. We pursue this mission through our my Place PACE (Program of All-Inclusive Care for the Elderly) model, which provides seamless primary care, integrated health plan coverage, personalized social engagement, and customized services delivered in the participant’s preferred place.

my Place Health is building a mission-driven team that shares our passion for redefining the way older adults experience care as they “age in place” in the community. This is a unique opportunity to take on one of our country’s most challenging healthcare problems and join a fast-growing, dynamic team as we prepare to scale our mission to serve more markets.

Are you passionate about making a difference in the lives of seniors? This is an exciting opportunity to join the Program of All-Inclusive Care for the Elderly (PACE) and play a vital role in supporting participants and their families. As an MSW, you’ll plan, organize, and deliver social work services tailored to the unique needs of each individual.

In this role, you’ll maintain a caseload of participants, collaborating closely with the Interdisciplinary Team (IDT) to ensure seamless, person-centered care. Acting as a trusted liaison between the PACE program and participants, families, and caregivers, you’ll foster meaningful relationships that support seniors in continuing to live independently  you’re driven to empower older adults to thrive within their communities, we’d love to have you on our team!

• Engage in daily IDT meetings to ensure participants' voices are heard, conducting psychosocial assessments and developing care plans during initial, semi-annual, annual, or emergency reviews.
• Present assessments at care plan conferences
  , laying the foundation for collaborative care plans crafted by the IDT team.
• Collaborate seamlessly with the IDT to guide participants through smooth care transitions between settings, such as hospitals, homes, and long-term or short-term care facilities.
• Connect participants, families, and caregivers with community resources and provide ongoing support tailored to their unique needs.
• Facilitate transitions between home and other placements
  , ensuring participants feel safe, supported, and empowered throughout the process.
• Support participants with Medi-Cal applications
  , staying up to date with changing regulations and coordinating communications with government agencies to ease the process.
• Coordinate advanced care planning in partnership with providers, ensuring participants' goals of care are thoughtfully addressed.
• Design and lead group counseling sessions and activities to promote emotional well-being, personal growth, and social engagement.
• Document care plans and interactions accurately and promptly in the EMR, ensuring smooth coordination across the care team.
• Provide discharge planning support when participants transition out of the program, helping them navigate the next steps with confidence and care.
• Embrace flexibility and teamwork by taking on other meaningful duties as assigned to enhance participant well-being and team success.

• Advanced training in social work: Master’s degree in Social Work (MSW) from an accredited university.
• Safety first mindset: CPR and First Aid certification required (or willingness to obtain within 30 days of hire).
• Hands-on clinical experience: At least 2 years providing psychosocial assessments, care planning, and case management support.
• Heart for older adults: Minimum 2 years working with frail or elderly populations, with a clear passion for protecting their dignity and well-being.
• Ready…