Geriatric Complex Care Coordinator North Brookfield Primary Care Part-Time with Opportunity to Grow to Full-Time | 20+ Hours/Week About North Brookfield Primary Care North Brookfield Primary Care is an independent, nurse practitioner-owned primary care practice serving patients in rural Central Massachusetts. We are not a large health system or traditional medical office. We have built our practice around the belief that excellent primary care means helping patients navigate not only their medical needs, but also the complicated systems and community services that allow them to remain safe and independent. We are growing our care management program and are looking for an experienced Complex Geriatric Care Coordinator who understands the unique needs of frail older adults and knows how to navigate the Massachusetts long-term services and supports (LTSS) system. This is an opportunity to help us build something different: a primary care practice where care coordination is integrated directly into the patient's healthcare team rather than functioning as a separate service. The Role The Geriatric Care Coordinator will work primarily with older adults who have complex medical, functional, social, and long-term care needs. You will work closely with our nurse practitioners and existing care management team to identify needs, connect patients and families with appropriate services, and help patients remain safely in their homes whenever possible. We are particularly interested in someone who already understands the Massachusetts elder-services system and can confidently navigate programs such as Aging Services Access Points (ASAPs), Personal Care Attendant (PCA) services, Adult Foster Care (AFC), MassHealth LTSS programs, home care services, transportation, food assistance, and other community-based supports. This is not primarily a front-desk or administrative position. We are looking for someone who enjoys solving complicated problems, knows how to find resources, and is comfortable advocating for older adults and their families. Responsibilities Conduct care coordination and needs assessments for older adults with complex medical and social needs. Identify functional, safety, social, transportation, food, housing, caregiver, and long-term care needs. Help patients and families navigate ASAP and community-based elder services . Assist with referrals and coordination for PCA assessments and services . Assist patients and families in exploring and accessing Adult Foster Care (AFC) when appropriate. Navigate MassHealth and other LTSS programs and community resources. Coordinate home health, durable medical equipment, transportation, meals, and other supportive services. Communicate with patients, caregivers, community agencies, ASAPs, home care organizations, and other members of the care team. Follow up to make sure referrals and services actually happen—not simply that an application or referral was submitted. Identify patients who may benefit from additional care management services and collaborate with the clinical team on care plans. Document care coordination activities clearly and accurately in the electronic medical record. Participate in interdisciplinary discussions regarding high-risk and frail patients. Help us continue developing and improving our geriatric care coordination program. Who We're Looking For We would especially like to hear from candidates with previous experience in elder services, LTSS, ASAPs, SCO programs, One Care, MassHealth, senior care organizations, home care, community health, complex care management, or similar programs. Strong candidates may come from backgrounds such as social services, community health, care management, elder services, case management, medical assisting, or other roles involving significant geriatric care coordination. Strongly Preferred Significant experience working with older adults and/or medically complex patients. Working knowledge of the Massachusetts LTSS system. Familiarity with ASAPs and community elder-service organizations. Experience with PCA, AFC, home care, and other community-based programs. Understanding of MassHealth eligibility and community-based benefits. Excellent communication and follow-through. Ability to work independently and figure out complicated systems. Comfortable communicating with patients, families, healthcare providers, and outside agencies. Strong organizational and documentation skills. Comfortable working in a small, growing practice where programs continue to evolve. Schedule This position will begin at approximately 20 hours per week , with the goal to increase toward full-time as the program grows. We are open to discussing scheduling arrangements with the right candidate. Compensation $26-$30 per hour , depending on experience, qualifications, and knowledge of Massachusetts geriatric and LTSS programs. Someone who can walk in with substantial experience navigating ASAPs, PCA, AFC, MassHealth LTSS, and community elder services would be considered toward the higher end of the range. Benefits As a small independent practice, our traditional benefits package is limited. We want to be transparent about that from the beginning. What we can offer is a flexible, supportive work environment, unlimited PTO , and the opportunity to have a meaningful role in shaping a growing program rather than simply stepping into a narrowly defined position. Why This Position Is Different Many older adults do not need another phone number or another referral—they need someone who understands the system well enough to help them actually get what they need. At North Brookfield Primary Care, the care coordinator is part of the primary care team. You will have direct access to the clinicians caring for your patients and the ability to identify problems, collaborate on solutions, and follow patients over time. Because we are independent, we can also build programs around what works for our patients rather than around the structure of a large healthcare organization. If you know the Massachusetts elder-services system, enjoy working with older adults, and like the idea of helping build a different model of rural primary care, we would love to hear from you.

Job Type:

Part-time, with opportunity to grow to full-time

Expected Hours:

Approximately 20 hours per week initially

Pay:

$26.00-$30.00 per hour

Pay:

$26.00 - $31.00 per hour

Benefits:

Paid sick time Paid time off

Work Location:

Hybrid remote in North Brookfield, MA 01535