Care Team Specialist (PACE)

Responsibilities

• Partner with the IDT to identify and act on participants’ goals, values, and preferences, ensuring care plans reflect What Matters Most (WMM).
• Build strong working knowledge of Patient Priorities Care (PPC) and Goal Concordant Care, and help embed these principles into everyday practice.
• Facilitate Care Team Meetings, Care Coordination Meetings, and Care Planning discussions, making sure documentation in the EMR is clear, timely, and accurate.
• Develop and maintain care planning, documentation, and compliance workflows aligned with regulatory requirements.
• Serve as an EMR superuser, supporting, guiding, and troubleshooting with team members as needed.
• Monitor completion of assessments, care plans, service determination requests, trackers, and other IDT deliverables, helping remove barriers when things get stuck.
• Act as backup for the Center Manager to help ensure assessments are completed within the required 30-day timeframe.
• Collaborate with Quality Improvement and Compliance to audit care plans and strengthen regulatory alignment.
• Provide support and supervision that builds confidence, clarity, and follow-through, fostering a culture of ownership and continuous improvement.
• Support the team in delivering care across settings, with attention to physical, emotional, and spiritual needs.
• Jump in to support other departments when needed (Admin, Home Care, Clinic, and more).

Qualifications

• A mission-first heart for seniors. Genuine passion for serving high-risk seniors and frail older adults.
• You thrive in a fast-paced environment and enjoy working in a collaborative, team-based culture.
• You naturally center the participant’s goals and help translate them into real, achievable care plans.
• The education and/or licensure to lead confidently. Bachelor’s degree in a relevant field (nursing, social work, healthcare administration, etc.) required; master’s preferred (MSW or healthcare administration).
• We will also consider an LVN or RN with 5+ years of experience leading an IDT.
• At least 2 years providing direct care (PACE or similar setting strongly preferred).
• Experience in value-based models. 1+ year in a PACE organization or value-based care environment.
• 3+ years of active participation on an Interdisciplinary Care Team.
• Strong communication skills and a proven ability to foster collaboration and hold others accountable with respect.
• Familiarity with PACE-related regulatory requirements and confidence operating in a highly regulated environment.
• Proficiency in Microsoft Word, Excel, and PowerPoint.
• Prior experience using Electronic Medical Record systems (and the curiosity to become a superuser).