Primary Accountability
Under the direct supervision of the Center Manager, the FHCN PACE Home Care Coordinator is responsible for the development and implementation of home care services for program participants, including the coordination of all Durable Medical Equipment (DME) and community-based care.
Description of Primary Responsibilities
- Assesses the home and personal care needs of the frail and elderly population and identifies and works with the Interdisciplinary Team (IDT) to develop specific plans of care. Initial and periodic assessments to be conducted minimally every 6 months and must be completed prior to the scheduled team meeting. Receives reports from home care staff and communicates participant changes to IDT members in a timely manner.
- Schedules and coordinates home care staff -both contract and/or employed, for in-home care delivery and the implementation of all personal care services to ensure that quality services are provided to meet participant needs.
- Coordinates all DME provisions in a home setting; works with IDT with DME authorization requests.
- Coordinate 24-hour care delivery.
- Document participant changes appropriately in the medical records and communicate participant changes to IDT in a timely manner.
- Supervise home care staff based in the community.
- Assist with competencies of home care aides; provide orientation, in-service training, and continuing education of designated staff.
- Keep up to date on home care standards and best practices.
- Ability to drive to community locations and residences to provide on-site training and competency checks of home care staff.
- Provide effective leadership by coordinating and integrating services within the department, with other departments, and with the IDT’s primary functions.
- Document participant changes appropriately in the medical records and communicate participant changes to IDT in a timely manner.
- Participate as a member of the IDT. Attend staff meetings and take part in participant care planning
- Other projects and duties as assigned.
Description of Primary Attributes
Professional & Technical Knowledge:
Effective June 1, 2026, all individuals hired into the role must:
- Possesses work-related skills at a higher level than completion of high school, including formal written and verbal communications skills, computational and computer skills, mathematical, and technical skills.
- Must have proof of completion of high school with a minimum overall GPA of 2.5 or completion of General Educational Development (GED) with a minimum overall score of 162.5 and health care related knowledge frequently acquired through completion of a trade school, para-professional, or certificate type program.
- If an individual has completed a degree at a higher level than required by the role and had a stronger GPA in that program, they may provide proof of GPA from that degree in lieu of the high school diploma or Bachelor’s degree.
- Have a minimum of two years of experience with a home health or community health provider, or equivalent experience.
- Work independently and collaboratively as an effective member of a team, while acting only within the authorized scope of practice. Provide care to geriatric participants, including assessing Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), collaborating with the Interdisciplinary Team (IDT) to determine home care needs, care planning, service frequency, and discharge, and communicating participant home care issues to the IDT in a timely manner.
- Schedule and coordinate home care staff to adequately meet participants’ home care needs.
- Travel to participants’ homes as required, potentially on a daily basis.
- Complete all required orientation and competency profiles and meet standardized position‑specific competencies established by FHCN PACE and approved by regulatory agencies prior to providing independent participant care.
- Obtain and maintain medical clearance for communicable diseases and ensure all required immunizations are up to date before engaging in direct participant contact.
- Successfully pass a criminal background check, verifying the candidate is not excluded from participation in Medicare or Medicaid programs and has not been convicted of criminal offenses related to healthcare fraud, abuse, or physical, sexual, drug, or alcohol abuse.
- Either have one year of experience working with a frail or elderly population or, in the absence of such experience, complete appropriate training provided by FHCN PACE upon hire.
Technical Skills:
- Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs, and other elements.
- Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables, and other standard spreadsheet elements.
- Ability to create basic presentations in Microsoft PowerPoint.
Licenses & Certifications:
- Current nursing license, if applicable. Valid CA driver’s license with a good driving record and an acceptable certificate of auto insurance.
- Currently certified in cardiopulmonary resuscitation (CPR), if CPR is not current, will be granted 30 days from the date of hire to schedule for the next available CPR certification class provided by FHCN.
Communications Skills:
- Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles, or other documentation.
- Effectively conveys technical information to non-technical audiences.
Physical Demands and Work Environment:
Physical demands: While performing duties of the job, the employee is required to move about the FHCN PACE center and actively engage with the interdisciplinary team and participants. Employees must be able to sit for extended periods of time, as well as work at the computer for long periods. Employees are required to use their hands and fingers, especially for typing on the computer and using the mouse. Employees must be able to talk and listen, particularly for phone communications.
Work Environment: Busy Adult Day Health Center (ADHC) and clinic environment serving the frail elderly with medium to loud noise levels and controlled office temperatures. Home environments of FHCN PACE participants when conducting needs assessments and supervising home care staff. Travel time in a vehicle for home visits.
Pay Scale:
Min Salary Rate: $21.56
Max Salary Rate: $29.75
