PACE Home Care Coordinator

Summary

The Home Care Coordinator is responsible for organizing and facilitating comprehensive care services for participants receiving home-based medical support. As a key member of the interdisciplinary team, this role ensures continuity of care by coordinating appointments, assessments, and follow-ups, while serving as a liaison between participants, families, providers, and external services. The Home Care Coordinator supports clinical operations, promotes patient-centered care, and contributes to quality improvement efforts.

Essential Duties

· Care Coordination and Management

· Clinical Support and Documentation

· Participant and Family Engagement

· Communication and Collaboration

· Operational and Program Support

Job Duties

· Coordinates the medical care of participants in assigned program, clinic, or service.

· Performs and documents developmentally appropriate physical assessments.

· Evaluates participant data and recognizes normal and abnormal findings.

· Uses critical thinking and problem-solving skills to work with participant and family to ensure an appropriate plan of care.

· Ensures physician plan of care is executed and that all tests, procedures, consults, and other necessary diagnostics are completed in a timely manner. Ensures relevant elements of the plan of care are performed prior to subsequent clinic visits.

· Develops therapeutic relationships with participants and families.

· Evaluates and documents participant/family responses to interventions and treatment protocols or guidelines.

· Safely performs any clinical skills and adjusts interventions to changes in participant/family status.

· Coordinates care across the continuum.

· Obtains reports and findings and collaborates with providers for further health care needs of the participant.

· Plans and implements a system of follow-up with participants regarding missed appointments, abnormal tests, and needed services.

· Provides timely follow-up and relevant updates to referring physicians as necessary.

· Schedules and coordinates appointments and services with the participant/family and appropriate providers.

· When applicable obtains necessary authorizations from third party payors for specialty care, diagnostics, DME, and community services

· Assists with the development and implementation of policies, procedures and protocols developed by team members.

· Monitors clinic access and ensures that new participants are seen in a timely manner to meet established expectations.

· Adjusts participant scheduling priorities as appropriate.

· Coordinates participant flow during clinic and delegates tasks as necessary.

· Works with physicians and management in formulating long range plans and goals for the assigned area including recommendations to improve clinic flow.

· Sets objectives and strategies for meeting the plans and goals for the assigned area.

· Contributes to planning, developing and implementing assigned area-based quality monitoring and evaluation activities and implements measures to ensure that applicable regulatory standards are met.

· Serves as role model to demonstrate the principles of participant and family centered care.

· Provides appropriate participant/family education and teaching.

· Acts as clinical resource in responding to expressed needs of nursing staff, management staff, participants and families and/or other disciplines.

· Communicates effectively with physician and provider partners.

· Understands, applies and supports departmental/hospital policies, procedures and standards.

· Provides support and education to nursing regarding current treatment and the clinical program.

· Coordinates and/or attends appropriate conferences supporting assigned program, clinic, or service.

· Provides educational in-services to staff as necessary.

Supervisory Responsibilities

This position does not have any supervisory responsibilities.

Qualifications

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Education:

· Active CNA and Home Health Aide (HHA) certification preferred

· Current CPR/BLS certificate

· 3+ year of experience working with frail or elderly adults

Experience

· Minimum of one year of personal, clinical/leadership, and/or employment experience providing care or services for a frail or elderly population required.

· Experience in a home health agency, community-based or long-term care setting involving the elderly preferred.

· Two years of community nursing preferred.

· Proficient in computer operations acquired either through work experience or education, including word processing and spreadsheet programs.

· Ability to understand and prepare moderately complex written materials.

· Excellent verbal and written communication skills.

· Ability to work without close supervision and to exercise independent judgment.

· Ability to organize multiple tasks and projects and maintain control of workflow.

· Ability to perform basic arithmetic calculations as would be acquired through completion of high school.

· Understanding of basic research principals and scientific methods.

Skills and Knowledge :

· Knowledge of physical, mental and social needs of frail older adults.

· Effective skills in physical assessment and chronic disease management for frail older adults.

· Effective listening and oral and written communication skills.

· Demonstrated ability to work effectively within the interdisciplinary team setting.

· Computer proficiency.

· Able to manage changing priorities per participant needs.

· Strong organizational skills.

· Demonstrates necessary skills and knowledge as outlined in the position-specific Competency Assessment Profile.

Desired Personal Attributes :

· Dependable, flexible and resourceful.

· Enjoys working with disabled and older adults.

· Effective interpersonal skills to work with members, caregivers and staff.

· Ability to work sensitively and effectively with individuals of diverse ethnic and cultural backgrounds.

· Ability to be self-directed and able to work independently

· Analytical, energetic, resourceful and flexible.

· Ability to work effectively and harmoniously with the staff, public and private agencies, government officials and local consumers.

· Advocate for community-based services and commitment to risk-based long-term care system to serve the frail elderly population of the community.

· Ability to work sensitively and effectively with individuals of diverse ethnic and cultural backgrounds.

Other:

· Must be able to work required schedule.

· Requires physical strength to perform essential functions of the job.

· Occasional travel between sites, nursing/group homes and to members’ homes required.

· Requires valid driver’s license.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

HIPAA/Compliance

Maintain privacy of all patient, employee and volunteer information and access such information only on a need-to-know basis for business purposes.

Comply with all regulations regarding corporate integrity and security obligations. Report unethical, fraudulent or unlawful behavior or activity.

NOTE: THIS JOB IS NON-EXEMPT UNDER FLSA PROVISIONS.

Innercare is an Equal Opportunity Employer. In compliance with the Americans with Disabilities Act, Innercare will provide reasonable accommodation to qualified individuals. Innercare encourages both incumbents and individuals who have been offered employment to discuss potential accommodations with the employer.

Job Type: Full-time

Pay: $23.00 - $29.00 per hour

Benefits:

• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Parental leave
• Referral program
• Retirement plan
• Vision insurance

Work Location: In person