PACE Participant Support Coordinator/Community Health Worker

Benefits effective Day 1
Schedule Monday - Friday Days
Mileage Reimbursement

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

•         Certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.

• Active BLS for healthcare professionals from the American Heart Association or Red Cross. Employees hired prior to 12/31/2022 must obtain certificate prior to 3/31/2023