Home Care Coordinator (RN)

Job Summary: 

The PACE Home Care Coordinator supervises staff to ensure regulatory compliance and quality while maintaining an optimal level of independence for participants for personal care performed both in the PACE Center and in the participant’s home.  He/she provides technical, organizational and interpersonal skills necessary to efficiently and effectively coordinate the scheduling, communication and documentation of all aspects of the plan of care for personal care and non-skilled home care.  The Home Care Coordinator promotes and maintains the health of participants in the community through teaching, counseling and appropriate preventive and restorative services.  He/she is responsible for assessment of non-skilled home health needs and contributing to the plan of care, initial implementation of care plans, and providing personal care, as well as periodic re-evaluation of individual and family personal care needs.  The Home Care Coordinator demonstrates the knowledge and skills necessary to assess, plan care for and provide service to frail, elderly participants according to assigned responsibilities and PACE Program standards. 

Essential Duties and Responsibilities: 

Home Care Coordination: 

         1.         Manages staff roster and schedules for all home care on a daily, weekly and monthly basis to create the most time-efficient and cost-effective schedule to meet the needs of PACE participants.

         2.         Designs systems for training, orienting, in-servicing, and supervising Center-based and in-home caregiver staff according to program needs and regulatory requirements.

         3.         Supervises Center-based and in-home caregiver staff and directs the provision of quality paraprofessional care by evaluating staff performance and making decisions regarding hiring and retention.. 

         4.         Effectively communicates with participants and their families regarding home care needs, concerns and/or problems with coverage.

         5.         Records, maintains, monitors and verifies accurate home care records, including service documentation, attendance/payroll, in-service, medical records, and billing of contracted services.

         6.         Obtains and tracks equipment, supplies and services, such as durable medical equipment, home-delivered meals, oxygen, medical-response systems, and incontinence supplies as reflected in the care plan. 

Assessment and Care Plan: 

         1.         Conducts an admission assessment to assess home care needs and contributes to the care plan process.

         2.         Participates in on-call coverage to troubleshoot, advise, teach and coordinate the scheduling of participant care.

         3.         Participates in the development and revision of the participant’s plan of care as a member of the Interdisciplinary Team.

         4.         Conducts periodic assessments and evaluations of each enrollee and arranges for non-skilled personal care in the home and/or PACE Center according to the plan of care.

         5.         Counsels and guides participants and families towards self-help in recognition and solution of physical, emotional and environmental health problems.

         6.         Compiles and uses records, reports and statistical information for evaluation and planning of the assigned programs.

         7.         Maintains timely and quality documentation of all services provided.

         8.         May participate in joint team/family meetings to discuss current services, concerns and suggestions for care plan updates and/or revisions.

         9.         Establishes and maintains cooperative working relationships with other program staff, contracted agencies and outside organizations.

       10.       In conjunction with the IDT, communicates effectively with hospital departments to minimize hospital lengths of stay, as appropriate, and allows for a smooth transition for the participant as he/she moves from the hospital to home.

       11.       Participates in quality management program activities, including peer reviews. 


         1.         Knows and adheres to the philosophy and goals of the PACE Program.

         2.         Maintains a quiet and safe environment for participants, visitors and staff.

         3.         Keeps confidentiality of participant records, reports and discussions.

         4.         Participates in formulation and maintenance of PACE Program policies and procedures.

         5.         Participates in PACE Program committees as requested by the Center Manager.  May chair committees and task forces as needed.

         6.         Advises the Program Director in ways and means to establish better accountability of PACE Program services to participants and referral sources.

         7.         Attends and participates in scheduled staff meetings and participant care meetings as requested. 

         8.         Maintains flexibility in schedule and responds to unexpected emergencies and changes in workload in order to fulfill responsibilities.

         9.         Utilizes supplies and equipment economically.

       10.       Informs the Program Director of unusual occurrences.

       11.       Identifies service delivery problems and uses good judgement in their solution.

       12.       Maintains applicable licensure and certification and pursues professional growth.

       13.       Performs other related duties as required.  Management reserves the right to add, delete or otherwise alter assigned duties at any time.  To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The minimum qualifications listed are representative of the knowledge, skill and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 


         1.         Education:

a.       Bachelor’s of Science in Nursing (BSN) preferred 

         2.         Credentials/Licensure Required:

a.       License and current registration to practice as Registered Nurse in Delaware 

         3.         Experience:

a.       Five or more years and thorough knowledge of current community health nursing practice

b.      Nursing, geriatrics, health care and home health experience

c.       Proficiency with Microsoft Word, Outlook, and Excel strongly preferred 

         4.         Age of Patients Rendered Care:

a.       Adult and geriatric patients 

*** Freedom from illegal use of drugs, and freedom from use and effects of use of drugs    and alcohol in the workplace. 

*** Persons who have been found guilty by a court of law of abusing, neglecting or mistreating individuals in a healthcare-related setting are ineligible for employment in this position. 

Knowledge and Skills: 

         1.         Working knowledge of the administrative organization of community facilities.

         2.         Ability to plan and coordinate personal and non-skilled home care services for individuals, families and groups.

         3.         Ability to communicate effectively.

         4.         Ability to establish and maintain cooperative working relationships.

         5.         Ability to supervise others in a direct, firm and understanding way.

         6.         Ability to accept and utilize guidance.

         7.         Interdisciplinary teamwork – ability to work effectively with culturally, economically and educationally diverse populations, and to form positive interpersonal relations when dealing with a wide range of staff and clients as essential

         8.         Proven leadership abilities.

         9.         Ability to understand the PACE Care medical management process.

       10.       Ability to conduct analysis of data and outcomes, and to develop systems and processes

       11.       Understanding of detailed State and Federal regulations that govern the PACE Program.

       12.       Basic understanding of automation and information technology management systems.

       13.       Ability to coordinate and collaborate with others in a team environment.

       14.       Ability to act as an advocate for the frail elderly.

       15.       Able to provide and encourage excellent customer service to participants.

       16.       Able to perform at a high level of autonomy for clinical and management decisions.


21 W Clarke Ave, Milford, DE 19963, USA
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industry: Healthcare