Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Executes assignments in a culture that is shared and collaborative across all divisions within Capital Health. Promotes and maintains collaborative relationships with managers, peers, direct reports, and customers by effectively fostering a team environment, building consensus, and resolving conflicts. Maintains department budget, places orders for equipment and supplies as necessary. Identifies financial vulnerabilities and makes cost reduction recommendations as needed. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior. Knows proper disaster recovery protocol, crisis management, and business continuity plans, and acts within role that is developed within the business continuity plan. Works at another location, remotely from home, and maintains constant contact with key personnel as required. Attends and participates in scheduled training, in-service training, mandatory annual in-service training, and educational classes as required and needed. Participates as a member of the interdisciplinary team (IDT). Communicates participant changes, and collaborates on care planning decisions and coordination for 24-hour care delivery. Performs initial, semi-annual, unscheduled, and annual assessments of participants. Coordinates with IDT to develop comprehensive plan of care for each participant. Participates in the development and implementation of QAPI activities. Conducts initial intake meeting with family members and others, while coordinating ongoing family meetings as needed. Provides individual and family counseling as needed or prescribed in the plan of care and develops and leads group counseling and support activities. Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model, and PACE health services. Maintains current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and participant's expressed wishes. Performs home visits periodically or as needed to asses living environment and support system. Assists with ongoing financial eligibility for participants, including recertification as needed. Provide training, supervision, oversight and evaluation to case managers and case management to participants and families. Acts as liaison between the participant and other agencies such as Department of Aging, Social Security Administration, and Medicaid. Acts as a resource to other team members, and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities. Assists participants and caregivers in filing grievances and appeals. Assures that any personal care needs are communicated to the family with special attention to clothing and DME needs while participants are in hospital or short-term rehab stays and communicate relevant information to the interdisciplinary team about participants while they are admitted. Coordinates discharge planning for participants returning home from hospital or nursing facility. Provides crisis intervention and advocacy as required. Actively provides emotional support, grief work, education, funeral and financial planning referrals when hospice care is appropriate. Facilitates hospice or nursing home placement as needed. Initiates referrals to external resources with community agencies such as Adult Protective. Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed. Coordinates transitional care to ensure continuation of care by assisting participants with reinstatement of conventional Medicare and Medicaid benefits, transitions care to other providers, makes referrals, and ensures participant medical records are available to new providers in the event of participant termination of the PACE Program. Performs other duties as assigned.
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Job Type
Full-time
Career Level
Mid Level
Number of Employees
501-1,000 employees