Full Time - : Open until filled
Job Summary: Responsible for the coordination of all home care services for PACE participants in their home.
Primary Responsibilities: Under limited supervision and in accordance with all applicable federal, state and local laws/regulations:
- Assesses participants' home care needs and completes Caes Manager Assessment during intake, semi-annual and annual re-evaluations as needed.
- Collaborates with participant and participant’s family and/or designated contact regarding plan of care
- Arranges for all home care services to participants including but not limited to: nursing visits, certified nursing assistant visits, laundry services, housekeeping services, shopping,
- Coordinates all Durable Medical Equipment in participant’s home
- Ensure the participant has all service interventions implemented to remain living safely in their home according to care plan
- participants care plan is reflective of all interventions that occur in participants’ home
- Participates in weekly interdisciplinary team meeting by giving an accurate picture of participant home environment.
- Collaborates with other PACE disciplines regarding participants medical and psychosocial needs at home.
- Attends outside medical appointments with participants when an escort is required
- Maintains accurate records of all services in EMR for care provided to participants at home.
- Assists with teaching and training caregivers regarding home care needs of participants.
- Completes PASSR screening initially and annually.
- Assists at intake and enrollment assessment with coordination of enrollment process.
Education: Degree in Nursing, Social Work, OT, PT or other related healthcare field from an accredited college or university. Experience may substitute for degree.
Experience: At least two years’ experience in healthcare field. One year’s experience with frail or elderly population preferred.
Licensure: If licensed, professional license must be current.
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 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. Must able to lift, turn, and roll over participants.
Working Conditions: Primarily inside, well-lit, climate controlled environment. Will require travel in various weather elements (rain, snow, cold, heat etc.) Will require frequent home visits. Potential exposure to infectious disease and environmental hazards. Frequent home visits. Reliable transportation required.