Employment Opportunities

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Home Care Coordinator RN or LPN

Northland PACE – Bismarck

Full Time -   : 01/31/2019

Appy on line at www.northlandpace.com or email cover letter and resume to Amanda Erickson at aerickson@northlandhealth.com

Job Summary: Provides coordination of all medical care, personal care, skilled nursing and in-home services.


Primary Responsibilities: The Home Care Coordinator’s duties shall include, but not be limited to:


  1. Assumes responsibility for nursing care for Northland PACE Program participants at home.
  2. Assesses participants’ home care and medication needs and plans appropriate nursing care during initial, semi-annual, annual and significant change evaluations; and on an as needed basis.
  3. Communicates and works with home care nurse, medication nurse and CNA scheduler to schedule all home care needs.
  4. Provides input to the physician/non-physician practitioner about medical and nursing needs.
  5. Provides teaching and training to caregivers and Participants regarding home care needs and chronic disease management.
  6. Communicates and engages the Participant and family members in their health care.
  7. Works with social worker regarding family and caregiver stress in caring for homebound participants.
  8. Triages participants who are not able to attend Day Center due to sudden illness, perception of illness at home, or inability to travel.
  9. Is prepared for, participates and attends in weekly interdisciplinary team meeting by giving an accurate picture of participant home environment.
  10. Is flexible and able to adjust schedule to meet complex needs of participants.
  11. Provides teaching and training to homecare staff regarding needs of participants.
  12. Maintains accurate records of all services provided to participants at home.
  13. Updates weekend On-Call Nurse of any expected changes in service over weekends and holidays.
  14. Communicates and collaborates with ER, SNF, Foster Care and Hospital Facilities as needed regarding the Participants needs and plan of care.
  15. Completes level of care screenings for Participants annually.
  16. Acts as a participant advocate for all assigned Participants.
  17. Completes change forms for Participants for transitions of care.
  18. Provides coverage for On-Call as scheduled by Director of Nursing.
  19. Assumes responsibility for accurate information in the Participant's electronic medical record.
  20. Documents home care assessments in electronic medical record for initial, semi-annual, annual and significant change evaluations and on an as needed basis.
  21. Ensure accuracy of Participant’s allergies, medications and immunizations in the electronic medical record.
  22. Assumes responsibility for Participant’s plan of care regarding home care and medical services.
  23. Documents and delivers services for Participants’ outside medical appointments and nursing services that are provided in the home.
  24. Follow-up on orders provided at outside medical appointments and internal orders as needed.
  25. Document all services provided in a timely manner in the Participant’s medical record.
  26. Assumes responsibility for professional activities and growth.
  27. Keeps abreast of current nursing knowledge, especially in the field of geriatrics by attending professional conferences and in-services.
  28. Participates in interdisciplinary team meetings, pre-care conferences, care conferences for assigned Participants
  29. Participates in scheduled staff meetings.
  30. Understands and follows Northland PACE Program policies and procedures.
  31. Demonstrates service excellence to all participants in job performance.
  32. Acts as a nursing consultant to other staff members.
  33. Maintains accurate records of visits for self and Home Care Staff for data collection.
  34. Other duties as assigned.

Employment Specifications:


Associates or Bachelor’s degree in nursing from an accredited college or university.




At least three years nursing experience preferred; home and/or community health experience desired.


One year’s experience with a frail or elderly population


Number and type of employees supervised:



Licensure, registry or certification required:

Current North Dakota nursing license.

Current, valid North Dakota driver’s license.


Special Training:


Must be able to work effectively with an interdisciplinary team. Must be able to communicate effectively. Must possess strong interpersonal and organizational skills. Ability to adapt to change in a positive/professional manner. Must possess the ability to effectively handle difficult and unusual interpersonal situations.

Must meet standardized competencies for standards of medical care and established for position. Must be medically cleared for communicable diseases. Must have all immunizations up to date before engaging in direct participant contact.


Physical Demands:

Must be able to see, hear, and verbally communicate. Must be able to move about freely and possess manual dexterity and visual acuity. Moderate amount of walking. Must be able to move about freely, lift and turn participants.


Working Conditions:

Primarily inside, well-lit, climate controlled environment; however, will require travel in various weather elements (rain, snow, cold, warm temperatures etc). Frequent travel for home visits. Must have reliable transportation. Potential exposure to infectious diseases and environmental hazards.