Masters Level Social Worker - Talent Community

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.

This is an exciting opportunity for a compassionate and mission-driven Master’s-level Social Worker (MSW) to join the my Place Health PACE Program (Program of All-Inclusive Care for the Elderly). In this role, you’ll plan, organize, and deliver social work services that support our participants and their families through every stage of their care journey.

As a key member of our Interdisciplinary Team (IDT), you’ll maintain a dedicated caseload of participants and collaborate closely with nurses, therapists, physicians, and other care professionals to create comprehensive, person-centered care plans. You’ll also serve as a trusted liaison between participants, caregivers, and the PACE program—ensuring that each person feels heard, supported, and empowered.

This role is primarily Center-based, with opportunities to conduct home and off-site visits as needed to ensure continuity of care. Most importantly, you’ll play a vital part in helping frail older adults continue living safely and independently in the place they call home.

At my Place Health, every interaction is an opportunity to bring compassion, dignity, and purpose to the lives of those we serve.

• Collaborate daily with a dynamic care team. Participate in daily IDT meetings to coordinate holistic participant care with fellow clinicians and support staff.
• Bring the whole picture into focus. Conduct psychosocial assessments and develop individualized care plans at enrollment, semi-annually, annually, and as needs arise.
• Empower participants to guide their own care. Present assessments and care goals that reflect each participant’s unique values, preferences, and priorities.
• Smooth the journey across care settings. Partner with IDT colleagues to ensure seamless transitions between hospitals, homes, and long- or short-term care facilities.
• Connect people to what matters. Provide community resources and referrals that strengthen support for participants, families, and caregivers.
• Be an advocate and navigator. Assist participants with Medi-Cal and other government benefit applications and renewals to maintain continuity of care.
• Champion future planning conversations. Coordinate advance care planning in partnership with primary care providers to ensure participants’ goals of care are honored.
• Keep communication clear and compliant. Complete all required documentation in the EMR promptly, accurately, and with attention to detail.
• Support smooth program transitions. Provide discharge planning and emotional support for participants who disenroll from the program.
• Lend a helping hand where it’s needed most. Step in to support your team and participants through other related duties that promote well-being and quality of life.

• We’re always looking for compassionate Social Workers who are dedicated to helping older adults live with dignity, purpose, and joy. Whether you’re guiding participants through care planning,…