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Masters Level Social Worker

4 weeks ago

Los Angeles, California, United States myPlace Health Full time
About myPlace Health
myPlace Health is a mission-driven organization committed to 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, enabling them to thrive in their homes and communities.

Our Mission
Our mission is to empower older adults to live independent lives. We pursue this mission through our myPlace PACE model, which provides seamless primary care, integrated health plan coverage, personalized social engagement, and customized services delivered in the participant's preferred place.

About this Role
We are seeking a skilled Masters Level Social Worker to join our team. As a key member of our Interdisciplinary Team (IDT), you will plan, organize, and deliver social work services tailored to the unique needs of each participant. You will maintain a caseload of participants, collaborating closely with the IDT to ensure seamless, person-centered care. You will also act as a trusted liaison between the PACE program and participants, families, and caregivers, fostering meaningful relationships that support seniors in continuing to live independently at home.

Key Responsibilities
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.

Requirements
Master's degree in Social Work (MSW) from an accredited university.
CPR and First Aid certification required (or must be obtained within 30 days of hire).
2 years of experience conducting psychosocial assessments, care planning, and case management.
2 years of experience working with frail or elderly populations, demonstrating a passion for supporting their well-being.
Current California Driver's License with a clean driving record and personal automobile insurance (required by State law).
Proficiency in EMR/EHR documentation preferred.
Experience collaborating with multidisciplinary or medical teams preferred, ensuring smooth coordination of care.
Bilingual abilities in English and Spanish, Cantonese, Mandarin, or Vietnamese are a plus and warmly welcomed.
Ability to lift and carry, or move items weighing up to 25 pounds to support participant needs when necessary.