Essential Responsibilities:

Assist in the development and management of participant care plans, addressing medical, social, and personal needs. Actively participate in the interdisciplinary team by offering clinical expertise in team planning and problem-solving. Assesses in-home care needs by doing an in-person assessment in the participant's home on admission and routinely thereafter, adjusting care plans as indicated. Evaluate, implement, and develop home care treatment plans for participants ensuring tight coordination and communication with the Interdisciplinary Team (IDT). Serve as the primary contact for participants, their families, and healthcare providers regarding the provision of home care services. Coordinate participant access to community resources and services, including social, medical, and rehabilitative services. Relay information to appropriate personnel using established communication channels and procedures. Communicate effectively, both verbally and in writing, with providers, participants, family members, and team members. Encourage and motivate participants to engage in activities, providing support. Teach and counsel participants and family members regarding care and safety. Maintain accurate records of activities, participant progress, and any changes in participants' conditions. Serve on various internal and external committees as required or designated. Participate in team meetings, caregiver groups, and special events as needed. Provide on-call coverage for direct patient care alongside other staff as necessary. Foster a safe and supportive environment conducive to the professional development of healthcare professionals. Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.

Supporting Responsibilities:

Meet department and company performance and attendance expectations. Follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned.

SUCCESS PROFILE

Work Experience:

A minimum of 2 years of experience in case management, care coordination, and/or home and community-based services is required. A focus on working with geriatric or frail populations is preferred.

Education, Certificates, Licenses:

A valid, active Oregon License in health field required (RN, OT, PT, LCSW, PTA, COTA). CPR certification (BLS or ACLS) is required. A valid driver's license is required.

Knowledge:

Strong organizational, communication, and interpersonal skills, with the ability to manage multiple tasks and prioritize effectively. Proficiency in working with individuals who have various health issues, concerns, and personalities. Experience with computers and various software applications, including Word, Excel, PowerPoint, and Outlook. Ability to work independently with minimal supervision. Each member of the PACE organization's staff that has direct contact with participants must meet the following conditions: Be legally authorized (for example, currently licensed, registered or certified if applicable) to practice in the State in which he or she performs the function or action. Only act within the scope of his or her authority to practice. Have 1 year of experience working with a frail or elderly population Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently. Be medically cleared for communicable diseases before engaging in direct participant contact. Competencies Building Trust Building a Successful Team Aligning Performance for Success Building Customer Loyalty Building Strategic Work Relationships Continuous Improvement Decision Making Facilitating Change Leveraging Diversity Driving for

Results Environment:

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills:

Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$83,212.29 - $137,300.29 Our Values We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business: We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements:

Work is performed in a clinic setting with typical healthcare exposures, including contact with bodily fluids, infectious diseases, and cleaning chemicals; PPE is provided and required. The role involves stooping, bending, sitting, standing, and moving between clinical areas for extended periods. May assist participants with mobility, including guiding, supporting, escorting, and occasional transfer assistance using proper body mechanics. Must be able to lift, push, pull, or carry up to 35 pounds occasionally and perform frequent repetitive motions such as typing and operating medical or office equipment. Some positions require occasional travel to PACE sites, participant homes, or external appointments. Must be able to speak clearly, understand verbal instructions, and interact professionally with participants, caregivers, and staff.

Disclaimer:

This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. 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