PACE Participant Support Coordinator

It’s inspiring to work with a company where people truly BELIEVE in what they’re doing!

When you become part of the Chapters Health Team, you’ll realize it’s more than a job. It’s a mission. We’re committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success!

Role:

Shared Responsibilities:
- Conduct home visits, phone calls, and follow up to engage participants.
- Document all patient interactions in the EMR promptly.
- Act as liaison between participant/family and care team.
- Participate in team meetings, trainings, and quality improvement projects.
- Promote Hope PACE's mission and values.
- Maintain confidentiality and professional boundaries.

Support for Nursing Case Managers:
- Assist patients in attending medical appointments and report attendance to Nursing Case Manager.
- Provide appointment reminders and follow up outreach related to healthcare visits.
- Observe and report medication compliance during home or community visits.
- Support patients in adhering to treatment and wellness goals using motivational interviewing.
- Record patient care interactions in the EMR within 24 hours.
- Communicate patient status or concerns to the Nursing Case Manager.
- Attend interdisciplinary care plan meetings to support care coordination.
- Manage assigned caseload, prioritizing based on medical acuity.
- Participate in clinical team huddles or rounds.
- Maintain HIPAA compliance when handling PHI.

Support for Social Workers:
- Build trusting relationships to identify unmet social or emotional needs.
- Refer participants to community resources for food, housing, transportation, etc.
- Assist with applications or follow ups for community based services.
- Help participants navigate non-medical systems (e.g., Social Security).
- Advocate on behalf of participants with service providers.
- Provide emotional support and culturally appropriate health education.
- Communicate social or behavioral changes to the Social Worker.
- Attend social work case review meetings or planning sessions.
- Collaborate to reduce psychosocial barriers to care.
- Promote participant autonomy, resilience, and community connection.

Experience Requirements

• 1–2 years of experience in community-based, public health, or social services preferred

• Experience working with older adults or underserved populations highly valued

• Prior experience in interdisciplinary teams or programs like PACE or home care is a plus

• Home visit, outreach, or case coordination experience beneficial

Education Requirements

• High school diploma or equivalent required

• Associate’s degree in a health-related field preferred (e.g., public health, human services)

• Medical terminology coursework or training beneficial

Licensure & Certification

• CNA, EMT, or MA preferred but not required

• Completion of formal CHW certification program preferred

• Valid driver’s license and reliable transportation required for field visits

This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.