Home Care Coordinator

PACE Place provides coordinated medical and social services to elders who want to remain in their home but need support to do so. PACE Place provides Medical, Rehabilitation, In-Home Assistance, Transportation, Social Work, and Day Center services for patients in our care. Position Summary The PACE Home Care Coordinator is responsible for the development and implementation of home care services for PACE Partners participants, including the coordination of all Durable Medical Equipment and nursing home care. Typical schedule: M-F, 8 am - 5 pm with on call rotation including some weekends PACE Center located on Ramona Blvd, Jacksonville, FL 32205 Essential Functions Assesses, using the nursing process, the homecare needs of a frail elderly population, and identifies and develops specific plans of care in accordance with PACE requirements Conducts timely home health care assessments, using the appropriate process for the homecare needs of a frail elderly population Conduct initial home care and home safety assessments in conjunction with the PACE intake coordinator, as indicated, to identify and mitigate risks in the home environment Identifies and develops specific plans of care for the participant, as well as for home health aides/CNAs providing home care services Ensure all services are implemented according to the participant’s individualized care plan developed by the IDT. Conduct routine home visits to assess participant needs, safety, and satisfaction with services. Adjust services promptly in response to changes in participant condition or IDT direction. Coordinates the implementation of all homecare services, which can include nursing, physical therapy, occupational therapy, speech therapy and personal care services, to ensure that quality service is provided to meet client needs Provide nursing services in the home in support to the nurse care managers as needed Coordinates all home health care services for PACE Partners participants Oversee scheduling of medical escort services to outside appointments. Attends and participates in the interdisciplinary process through the Interdisciplinary Team (IDT) meetings Actively participate in IDT meetings and contribute to care planning and ongoing evaluation. Communicate changes in participant status to IDT members in a timely manner. Advocate for participant needs and preferences in care planning discussions Assess the program’s homecare services system, makes recommendations, and offers solutions to revise or modify systems to better meet participant needs Monitor service utilization and ensure alignment with authorized care plans. Participate in audits, quality improvement initiatives, and corrective action plans as needed. Provides oversight to contracted Home Health Aides (HHA’s) ensuring documentation is received timely and care planned items are provided to the participants Remains abreast of PACE Partners policy, processes, and procedures Performs evaluations of Home Health Aides (HHA’s) and completes supervisory and participant satisfaction visits to ensure care is being delivered in accordance with PACE standards and requirements Monitor participant satisfaction and address concerns or complaints related to home care services. Ensure services promote participant dignity, independence, and safety. Complete ongoing home safety assessments as indicated or recommended by the IDT. Comply with all state and/or federal regulations to ensure provision of services are documented, tracked, and monitored across all care settings. Comply with all state and/or federal regulations to ensure the required in-person assessments are completed in response to Service Determination Requests. Comply with all state and/or federal regulations to ensure the organization is performing assessments, collecting and analyzing the data from these assessments to take actions to improve the quality of the participant’s life. Comply with all state and/or federal regulations to ensure unscheduled reassessments are being conducted as required. Comply with all state and/or federal regulations to ensure the IDT coordinates 24-hour care delivery that meets the needs of each participant across all care settings. Comply with all state and federal regulations to ensure that all ordered, approved, or care planned services are provided to the participant. Comply with all state and/or federal regulations to ensure all complaints regarding quality of care or service delivery are properly processed as a grievance. Comply with all state and/or federal regulations to ensure all individual issues within a grievance are reviewed, considered, and resolved. Comply with all state and/or federal regulations to ensure immediately approved SDRs have notification of the approval during the same encounter and/or interaction. Comply with all state and/or federal regulations to ensure all participant medical records are complete, accurate and accessible to all staff. Only act within the scope of his or her authority to practice Performs other duties as assigned Qualifications Knowledge and Critical Skills Nursing, geriatrics, healthcare, and home health Interdisciplinary teamwork Ability to work effectively with culturally, economically, and educationally diverse populations Ability to form positive interpersonal relationships in dealing with a wide range of employees and participants are essential Working knowledge of the administrative organization of PACE Partners Skill in the application of current nursing procedures and techniques of patient care Ability to plan and coordinate nursing care for individuals, families, and groups Ability to receive and provide guidance Ability to perform duties in accordance with the ANA Code for professional nurses Knowledge of common safety hazards in the home and improvements to establish a safer environment Skilled in identifying problems and recommending solutions Knowledge of home care services nursing principles and practices with particular reference to the elderly Ability to do physical assessments and develop plans of care Knowledge of health counseling techniques and practices Skilled in preparing and maintaining records and written reports and responding to correspondence Excellent organization and documentation skills Previous management and leadership experience in home healthcare, preferred Familiarity with community health resources, which are available to participants and families Skilled in developing and maintaining department quality assurance Knowledge of Florida home health policies Skilled in establishing and maintaining effective working relationships with participants, medical staff, staff members and family caregivers Ability to react calmly and effectively in emergency situations Solid knowledge of Microsoft Word, Excel, PowerPoint, and Outlook Working knowledge of healthcare software systems Experience 1 plus years’ thorough knowledge of working with patients who have dementia 1 plus years’ experience working with the frail and elderly population, preferably in a home health, long-term care, assisted living facility or community health setting. 1 year of experience working with a frail or elderly population OR, if the individual has less than 1 year of experience but meets all other job requirements, the candidate must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring. Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently. Familiarity with Home and Community-based waiver programs Supervisory experience, a plus Bi-lingual Spanish, desired License / Certification Valid LPN License Valid current Florida state Registered Nursing license and registration, or appropriate commensurate licensing, as applicable Current Florida driver’s license and proof of active auto insurance coverage BLS Certification required Education Graduate from an accredited Practical Nursing Program Associate’s or Bachelor’s degree in nursing Other Requirements Must have medical clearance for communicable diseases and have up-to-date immunizations before direct participant contact. The knowledge, skills and abilities listed above are typically acquired through the levels of education and experience listed. However, any equivalent combination of education and/or experience, which provide an applicant with the listed knowledge, skills, and abilities to perform the essential duties and responsibilities of the job, is acceptable. This description is intended to describe the general nature and level of work performed by employees assigned to this role. It is not intended to be an exhaustive list of all duties, responsibilities, qualifications, or working conditions required of employees in this position. The organization reserves the right to modify or amend the duties of the position or to require that additional tasks be performed as organizational needs change. This description does not constitute a contract of employment, and employment with the organization is at-will, meaning either the employee or the organization may terminate the relationship at any time, with or without cause or notice. ADA Statement / Disclaimer PACE Place is committed to complying with all applicable provisions of the Americans with Disabilities Act (ADA), as amended. We provide reasonable accommodations to qualified individuals with disabilities to ensure equal access to employment opportunities and the ability to perform the essential functions of a position. If you require an accommodation to complete the application process, interview, or perform the essential functions of a role, please contact Human Resources at [email removed]. We participate in E-Verify to confirm the employment eligibility of all newly hired employees. Where applicable, and as required by law, employment with PACE Partners of Northeast Florida may be contingent upon successful completion of a background screening initiated by the organization through the Florida Agency for Health Care Administration (AHCA) Background Screening Clearinghouse. More information about the Clearinghouse, including positions that require screening, can be found here:. Equal Opportunity Employer Employment Type: Full Time