PACE Home Care Coordinator

ESPERANZA HEALTH CENTERS•Chicago, IL

50m•Onsite

About The Position

PACE, or Program of All-Inclusive Care for the Elderly, is an alternative care model for those over 55 years of age requiring nursing home level of care which aims to keep participants living at home in the community. PACE is a collaborative, interdisciplinary approach which coordinates all levels of medical and social needs, including prevention, wellness, socialization, primary care, and access to specialists and other services. The Home Care Coordinator (HCC) supports PACE participants in safely remaining in their homes by coordinating, monitoring, and supporting home-based services. This role focuses on serving as a member of the Interdisciplinary Team (IDT), assessing functional needs in the home environment, coordinating personal care and homemaker services, and serving as a liaison between participants, caregivers, contracted home care agencies, and IDT. The HCC ensures services align with participant goals, safety needs, and the interdisciplinary plan of care.

Requirements

Graduate of an accredited professional programs for RN; minimum BSN required.
Current CPR/BLS (Basic Life Support) certification through the American Heart Association
Strong verbal and written communication skills, with the ability to communicate clearly and compassionately with participants, caregivers, vendors, and interdisciplinary team members.
Excellent interpersonal skills, including the ability to build rapport with participants and families and collaborate effectively within a multidisciplinary healthcare team.
Demonstrated organizational skills and attention to detail, particularly in managing schedules, documentation, and coordination of home care services.
Effective time management skills, with the ability to manage multiple priorities, meet deadlines, and respond to changing participant needs.
Strong clinical reasoning, analytical, and problem-solving skills to assess participant needs, identify risks, and recommend appropriate interventions.
Ability to prioritize tasks independently and adjust workflow based on participant acuity, care needs, and program priorities.
Ability to act with professionalism, integrity, discretion, and confidentiality in accordance with HIPAA, PACE, and organizational standards.
Working knowledge of PACE regulations, CMS requirements, and interdisciplinary care models.,
Knowledge of home safety principles, ADL/IADL performance, adaptive strategies, and functional maintenance concepts relevant to older adults and individuals with disabilities.
Ability to provide clinical support under supervision, follow established treatment plans, and operate within defined scope of practice.
Proficiency in using electronic health records (EHRs) and the ability to accurately document assessments, care coordination, and clinical services.
Proficiency with Microsoft Office Suite (Word, Excel, Outlook) and the ability to learn PACE-specific systems and workflows.
Ability to work effectively in home, community, and center-based environments, including conducting in-home assessments.
Ability to maintain flexibility and resilience while working in a fast-paced, participant-centered healthcare setting.

Nice To Haves

Experience working with older adults, individuals with chronic conditions, or medically complex populations
Experience in home care, community-based services, hospice, long-term care, PACE or similar models
Familiarity with ADL/IADL training, home safety assessments, and functional maintenance programs
Bilingual (English/Spanish) preferred

Responsibilities

Conduct in-home assessments for PACE enrollment and ongoing post-enrollment evaluations to assess functional abilities, environmental safety, the need for personal care, homemaker services, or home modifications.
Serve as the primary liaison between Panorama PACE and contracted home care agencies with regards to managing service delivery, ensuring clear communication and continuity of services.
Performs all functions and duties as required as a member of the PACE Interdisciplinary Team (IDT), including, but not limited to, participation in IDT meetings, family conferences, grievances, service determination requests, CMS audits.
Coordinate, schedule, and manage home care services (e.g., Home Health Aides/HHAs), homemaker services, and HHA accompaniment for medical appointments to support participant safety and access.) in accordance with each participant’s individualized plan of care.
Along with PACE Site Director, monitor the quality, appropriateness, and effectiveness of home care services and address concerns related to service delivery or participant safety.
Communicate changes in participant status, functional ability, behavior, or home environment to the Interdisciplinary Team (IDT) in a timely manner.
Collaborate with IDT members to support participant independence, safety, and prevention of functional decline.
Participate in care planning, reassessments, and IDT meetings, including family conferences, service determination requests, grievances, and audits, as assigned.
Educate participants and caregivers on safe performance of Basic Activities of Daily Living (BADLS) Instrumental Activities of Daily Living (IADLs), adaptive strategies, environmental modifications, and risk-reduction techniques.
Ensure accurate, thorough, and timely documentation in the electronic health record (EHR) in accordance with PACE, CMS, and organizational standards.
Ensure compliance with PACE and state and federal regulations related to home care services and participant safety.
Participate in the PACE Quality Improvement (QI) program, contributing to initiatives that improve care delivery and participant outcomes.
Provide education, consultation, and support to PACE staff as needed to address participant functional and home care needs.
Deliver all services in alignment with the PACE philosophy, Illinois State Practice Act, and applicable professional standards.
Provide clinical coverage as assigned to support participant care delivery, in accordance with professional licensure, scope of practice, and PACE program requirements.