PACE Participant Support Coordinator/Community Health Worker

Chapters Health System•Naples, FL

17d•$20 - $28

About The Position

It’s inspiring to work with a company where people truly BELIEVE in what they’re doing! When you become part of the Chapters Health Team, you’ll realize it’s more than a job. It’s a mission. We’re committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success! Benefits effective Day 1 Schedule Monday-Friday - Days Mileage Reimbursement

Requirements

1–2 years of experience in community-based, public health, or social services preferred
Experience working with older adults or underserved populations highly valued
Prior experience in interdisciplinary teams or programs like PACE or home care is a plus
Home visit, outreach, or case coordination experience beneficial
High school diploma or equivalent required
Associate’s degree in a health-related field preferred (e.g., public health, human services)
Medical terminology coursework or training beneficial
CNA, EMT, or MA preferred but not required
Completion of formal CHW certification program preferred
Valid driver’s license and reliable transportation required for field visits
Certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.
Active BLS for healthcare professionals from the American Heart Association or Red Cross.
Employees hired prior to 12/31/2022 must obtain certificate prior to 3/31/2023
This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.
All Chapters Health System employees performing services for Florida affiliates are submitted through the Florida Care Provider Background Screening Clearinghouse to verify eligibility after a conditional offer of employment is made as well as ongoing eligibility.

Responsibilities

Conduct home visits, phone calls, and follow up to engage participants.
Document all patient interactions in the EMR promptly.
Act as liaison between participant/family and care team.
Participate in team meetings, trainings, and quality improvement projects.
Promote Hope PACE's mission and values.
Maintain confidentiality and professional boundaries.
Assist patients in attending medical appointments and report attendance to Nursing Case Manager.
Provide appointment reminders and follow up outreach related to healthcare visits.
Observe and report medication compliance during home or community visits.
Support patients in adhering to treatment and wellness goals using motivational interviewing.
Record patient care interactions in the EMR within 24 hours.
Communicate patient status or concerns to the Nursing Case Manager.
Attend interdisciplinary care plan meetings to support care coordination.
Manage assigned caseload, prioritizing based on medical acuity.
Participate in clinical team huddles or rounds.
Maintain HIPAA compliance when handling PHI.
Build trusting relationships to identify unmet social or emotional needs.
Refer participants to community resources for food, housing, transportation, etc.
Assist with applications or follow ups for community based services.
Help participants navigate non-medical systems (e.g., Social Security).
Advocate on behalf of participants with service providers.
Provide emotional support and culturally appropriate health education.
Communicate social or behavioral changes to the Social Worker.
Attend social work case review meetings or planning sessions.
Collaborate to reduce psychosocial barriers to care.
Promote participant autonomy, resilience, and community connection.