PACE Home Care Coordinator - East Region (Must have CNA & HHA)

San Ysidro Health•El Cajon, CA

About The Position

The PACE Home Care Coordinator HHA is a collaborative member of the interdisciplinary team (IDT) and provides foundational support to the Home Care Coordination team under the supervision of the San Diego PACE Home Care Coordination RN Manager. The role conducts home safety evaluations and coordinates and monitors IDT-approved services, including meal delivery, caregiver services, durable medical equipment (DME), and incontinence supplies. The coordinator advocates for participants’ healthcare needs and preferences and helps ensure unskilled home-based care is person-centered, compassionate, and aligned with participants’ goals. The coordinator works closely with participants, families, healthcare providers, vendors, and IDT members to arrange services, monitor schedules and service quality, identify gaps, and recommend care-plan adjustments. The role documents actions and service delivery in designated logs and electronic medical records, conducts visits, supports nurses, and assists participants with surveys and delivery of needed supplies.

Requirements

One year of experience with the frail or elderly population.
CNA (Certified Nursing Assistant) and HHA (Home Health Aid) certifications.
Valid California driver’s license and vehicle insurance.
CPR and First Aid (BLS) certification from the American Heart Association.
Effective oral and written communication skills and ability to follow written and oral instructions.
Attention to detail when typing and proofreading materials.
Ability to communicate effectively and work collaboratively.
Basic computer skills, including Microsoft Suite, Outlook, and Excel.
Strong organization, responsiveness, initiative, and ability to collaborate while independently executing tasks.
Skills necessary to coordinate and evaluate services for geriatric participants.
Firm understanding of the Home Health Aide scope of practice and ability to work within that scope.
Professional and personable demeanor to maintain excellent working relationships.
Ability to solve problems and identify opportunities and potential challenges.
Ability to maintain confidentiality and discretion and deal effectively and tactfully with staff, patients, and the public.
Ability to meet pre-employment requirements, including I-9, physical, positive background and reference check results, completed application, new-hire orientation, and pre-employment PPDs.
Compliance with all mandated vaccinations and boosters as a term and condition of employment.
Ability to meet the physical demands of continuous standing, walking, and twisting; occasional lifting, pushing, and/or transferring of participants weighing approximately 100 to 200 pounds; and frequent travel to participant homes, SYH sites, and San Diego PACE sites.

Responsibilities

Coordinate IDT-approved meal delivery to participants’ homes.
Coordinate IDT-approved delivery of durable medical equipment and incontinence supplies.
Coordinate IDT-approved caregiver services for participants.
Complete the Home Care Coordination care plan at enrollment and semi-annually thereafter as an IDT member.
Conduct pre-enrollment, annual, semi-annual, and change-of-address home safety evaluations.
Document and track actions, services, and service-delivery updates in designated logs and participant EMRs according to clinical, DHCS, and CMS regulations and guidelines.
Review progress notes and service-delivery documentation, and inform the IDT of service gaps for reconciliation.
Upload progress notes, reports, and care- or vendor-related documentation to the EMR.
Communicate regularly with participants, families, and healthcare providers to support coordinated care.
Advocate for participants’ healthcare needs and preferences and promote person-centered, compassionate care.
Support SD PACE nurses in coordinating and delivering meals, DME, and caregiver services.
Collaborate with physicians, social workers, therapists, and other interdisciplinary team members to coordinate participant care.
Follow infectious disease precautions to prevent the spread of organisms.
Attend center staff meetings and in-service educational training programs.
Assist Home Care Coordination RNs as requested.
Conduct and document monthly visits for homebound and RCFE participants.
Conduct home visits as needed.
Assist participants with surveys.
Deliver supplies, equipment, grocery bags, and other items as requested or needed.
Generate and maintain reports on services provided to participants.
Communicate and work effectively with participants and coworkers, and participate in IDT meetings as needed.
Follow SYHC and PACE attendance and punctuality policies and established PACE, ADHC, departmental, and position-specific policies and procedures.
Attend required meetings and participate in committees as directed.
Maintain health and safety standards, participate in the Safety and Injury Prevention in the Workplace Program, and maintain required records and documentation.
Perform other related duties as assigned or requested.