Home Care Coordinator- RN- PACE

Job Overview

The PACE Home Care Coordinator is a member of the PACE Interdisciplinary Team (IDT) and is responsible for completing home care assessments for new PACE participants and home care reassessments for existing PACE participants as part of the PACE IDT care planning process.

Job Responsibilities

• Participates as a PACE Interdisciplinary Team (IDT) member and is responsible for completing comprehensive initial home care assessments for new PACE participants and home care reassessments on existing PACE participants as part of the PACE IDT care planning process.
• In collaboration with the IDT, develops and implements home care plans for participants, identifying and considering the medical, physical, social, and emotional needs of PACE participants.
• Completes home care documentation in the PACE EHR in accordance with the federal PACE regulation and organizational policy.
• Utilizing PACE home care staff and home care contracted providers, schedules and monitors in-home care delivery consistent with individual participant care plans.
• Proactively and continuously communicates with PACE home care staff and home care contracted providers and relays participant status changes to IDT members promptly.
• Maintains monitoring of PACE participants for health or psychosocial status changes requiring a home care reassessment. Promptly communicates pertinent changes in participant status to the IDT.
• Attends IDT and morning meetings and reports on participant status changes.
• Coordinates durable medical equipment and other assistive devices delivery and maintenance in the home setting.
• Supports the PACE QI program and participates in PACE QI activities as assigned.
• Assists with case management and care coordination during care transitions and proactively communicates with hospital and long-term care facility case managers regarding participant discharge plans.
• Assists with determining the qualifications, competency, and performance expectations of PACE home care staff and home care contracted providers.
• Provides orientation, in-service training, and continuing education to PACE home care staff and contracted providers.

Job Requirements

• Bachelor's Degree - Nursing
• Nursing (Preferred)
• 1 - 2 years of experience with home or community health provider. (Preferred)
• Other Current Nursing License, If Applicable.
• Preferred Basic Life Support (BLS) Certification.