Who Are We and What We Do? The Detroit Area Agency on Aging (DAAA) Region 1-A is a private, non-profit organization responsible for planning, coordinating, developing, and funding services for older adults in the cities of Detroit, the five Grosse Pointes, Hamtramck, Harper Woods, and Highland Park.
We’re seeking a talented and motivated
Chronic Care Coordinator, RN to join our innovative team. Home-Based Primary Care is a newly established, start-up department. As such, this individual should be prepared to engage in building processes, navigating evolving structures, and contributing to the foundation of the program.
This role requires a high level of commitment, adaptability, and accountability. The coordinator must possess a strong work ethic, the capacity to manage complexity, and the depth of professional judgment necessary to serve a vulnerable population with excellence. The expectations are significant, and success in this role demands resilience, initiative, and a dedication to delivering high-quality, patient-centered care.
The Chronic Care Support Coordinator supports participants enrolled in DAAA’s Home Based Primary Care Program by coordinating person-centered services that help participants manage chronic conditions, remain safely at home, and access the medical, behavioral health, social, and community resources needed to support their overall well-being. This position works closely with participants, caregivers, providers, and the HBPC care team to identify needs, develop and monitor individualized care plans, support transitions of care, address social drivers of health, and promote continuity of care. If you're passionate about serving the aging population and thrive in a collaborative environment, we want to hear from you.
We invite you to apply and be part of a team that truly values your contribution. We offer competitive wages and are committed to fostering a workplace where growth, teamwork, and serving the aging population are at the forefront.
The Benefits of Joining Our Team - We Offer:
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Comprehensive Health Coverage - including medical, dental and vision
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Generous Paid Time Off
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Pet insurance
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Prescription drug insurance
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403(b)
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Flexible work week schedule
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Supportive Culture - A collaborative and inclusive environment where your ideas are valued
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Career Development and Opportunities for Advancement
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Employee Recognition
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Other attractive benefits
Essential Duties Performed:
- Develop, implement, and monitor person-centered care plans based on participant goals, preferences, strengths, medical needs, functional needs, caregiver input, and identify barriers to care.
- Conduct participant outreach, intake support, assessments, reassessments, and ongoing follow-up for individuals enrolled in the Home-Based Primary Care Program. Coordinate services and supports that assist participants in managing chronic conditions, including but not limited to diabetes, hypertension, mobility challenges, medication-related concerns, behavioral health needs, nutrition needs, and other complex health or social needs.
- Monitor participant status and promptly document and communicate changes in physical health, behavioral health, functional ability, caregiver support, safety, access to care, or social needs to the appropriate HBPC team member.
- Facilitate care transitions following hospitalization, emergency department visits, skilled nursing facility stays and any other inpatient or partial hospitalization setting
- Maintain regular contact with participants, caregivers, providers, and community partners through phone calls, virtual communication, and other HIPAA approved methods.
- Assist participants and caregivers in understanding care plan goals, available services, provider recommendations, and next steps in a manner that supports informed choice and participant engagement.
- Coordinate referrals and connections to community resources, including food, housing support, transportation, home repair, caregiver support, benefits assistance, behavioral health, home health, and other supportive services as appropriate.
- Collaborate with nurse practitioners, nurses, community health workers, social workers, medical assistants, billing/support staff, and other HBPC team members to support coordinated, interdisciplinary care.
- Promote participant choice, dignity, independence, cultural responsiveness, and safety in all service planning and coordination activities.
Documentation, Compliance, and Quality
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Complete all documentation accurately, thoroughly, and within required timelines, including assessments, reassessments, care plans, service notes, referrals, follow-up contacts, participant updates, incident-related documentation, and required reports.
- Maintain exceptional attention to detail in documenting participant needs, interventions, outcomes, service gaps, provider communication, and follow-up actions.
- Use designated electronic systems and documentation tools to enter, update, track, and retrieve participant information and program data.
- Support quality assurance activities by maintaining complete records, responding to documentation review findings, and correcting documentation issues in a timely manner.
- Maintain participant confidentiality and handle all participant information in accordance with HIPAA, privacy requirements, DAAA policies, and applicable program standards.
- Participate in team meetings, supervisory meetings, trainings, case conferences, in-services, and continuing education opportunities.
- Support program performance goals by tracking participant contacts, service coordination activity, care plan progress, and other required metrics.
- Maintain professional communication with participants, caregivers, providers, internal departments, and external partners.
- Perform other duties as assigned to support the Home-Based Primary Care Program and DAAA’s mission.
Education:
- Possess a valid Registered Nurse License in the State of Michigan
Education:
- A valid Registered Nurse license in the State of Michigan is required.
Experience:
- Two to three years of experience completing intakes, assessments, care coordination, chronic care support, case management, or related services in health care, home-based care, aging services, or human services setting preferred.
- Experience working with older adults, adults with disabilities, homebound individuals, caregivers, and individuals with chronic or complex health conditions preferred.
- Demonstrated experience developing, monitoring, and documenting person-centered care plans.
- Exceptional documentation, organization, and time management skills required.
- Ability to complete assessments and documentation using computerized systems and electronic records.
- Strong verbal and written communication skills, including the ability to communicate clearly with participants, caregivers, providers, and interdisciplinary team members.
- Excellent customer service skills and the ability to de-escalate concerns professionally and compassionately.
- Knowledge of Medicare, Medicaid, chronic care management, care transitions, community resources, and social drivers of health preferred.
- Computer literacy required, including Microsoft Word, Excel, Outlook, and related electronic documentation systems.
- Current Michigan driver’s license and access to reliable transportation required.
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Bilingual skills are strongly preferred.
The individual should have exceptional listening skills, an important level of energy and integrity; compassion for the elderly and the community as well as the staff; is centered and mature; exercises durability and adaptability. Values fun in the workplace as an integral instrument of staff motivation and operates with a spirit of excellence
