PACE Care Transitions Care Coordinator

Join the Team Voted Best Place to Work!

Why Work for Gary and Mary West PACE?

Because you're looking for more than just a job - you want work/life balance and the opportunity to make a meaningful impact in the lives of North County seniors and their families.

At Gary and Mary West PACE, we support your personal and professional well-being with:

• Generous pay and a comprehensive benefits package focused on your health and wellness.
• 11 paid holidays, 13 days of PTO, and 5 days of sick time.
• A 5% employer match to our 403(b) retirement plan.
• No on-call time – because your time matters.

We invest in our team with an annual education allowance and a commitment to professional growth, helping you expand your skills and advance your career.

You'll thrive in a supportive, mission-driven culture where collaboration feels like family. As part of our multi-disciplinary team, your voice is heard, and your work is truly valued.

Join us and do your best work - because here, your contribution matters.

The Gary and Mary West PACE (GMWP) Care Transitions Coordinator works closely with the RN Case Manager to assist in ensuring smooth transitions across levels of care for participants. The Care Transitions Coordinator facilitates and aids in communication, and problem‑solving skills to achieve optimal clinical and resource outcomes. Promotes quality of care by minimizing fragmentation, maximizing coordination, and facilitating participant movement through the health care organization.

• Collaborates with RN case managers/supervisors as needed or required.
• Creates a balance between individual clinical needs with the efficient and cost‑effective utilization of resources while promoting quality outcomes.
• Assists RNCM in implementing a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address.
• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.
• Actively assists Pace RN Case Managers, providers, hospital, and RCFE staff in the care management of affected PACE participants by establishing and facilitating regular and ongoing channels of communication.
• Actively assists Pace RN Case Managers with collaborations with providers, other members of the interdisciplinary health care team, participants, and caregivers, in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriateness of resources.
• Participates in the interdisciplinary team to formulate Plans of Care for PACE participants, as well as in other interdisciplinary team settings that plan, coordinate and monitor the care of PACE participants in institutionalized settings.
• Ensures PACE plan of care is communicated and adhered to by the contracted RCFEs where PACE participants reside through regularly established joint conference meetings.
• Provides or coordinates PACE or Participant‑related education to the contracted.
• Acts as the liaison between PACE and contracted RCFE facilities to assure all appropriate and essential services are implemented timely and efficiently for PACE participants.
• Oversees the coordination of specialty appointment, Day Center, and other scheduling needs for the participants residing in RCFEs.
• Conduct regular visits (as appropriate) to contracted RCFEs where PACE participants are residing to facilitate care‑coordination.
• Documents all necessary information in the EMR and maintains participant medical record(s), per PACE policies and procedures.
• Participates in the development implementation, and maintenance of a current nursing care plan for participants residing in RCFEs, in cooperation with the Clinic Nurse and the IDT.
• Maintains accurate medical records from hospitalizations and any other transitions of care for participants residing in RCFEs, including the management of documents of in hospital stay and examination results for participant records.
• Communicates effectively with the participants, interdisciplinary team, family members and caregivers, and others.
• Other duties assigned.