Community Resource Specialist

Community Resource Specialist – PACE Program

Your knowledge of community resources can remove barriers to care.
Your support can help older adults live safely, independently, and with dignity.

At Blue Ridge Care, our mission is simple: delivering extraordinary care to improve life's journey. As a not-for-profit, mission-driven healthcare organization, we support older adults and those facing serious illness through integrated services, including hospice, serious illness care, PACE, grief support, and community thrift shops.

Our PACE (Program of All-Inclusive Care for the Elderly) team provides comprehensive, coordinated care that allows participants to remain living in their homes and communities for as long as possible. The Community Resource Specialist plays a vital role in helping participants access essential services, benefits, and community resources that support their overall well-being and quality of life.

We are seeking a compassionate, organized, and resourceful Community Resource Specialist to work closely with participants, caregivers, designated representatives, and the interdisciplinary team. In this role, you will help identify and secure community resources, assist with public benefit programs, provide participant education, and support care coordination efforts that address social, emotional, and financial needs.

You will serve as a trusted resource and advocate, helping participants navigate complex systems while ensuring access to the services necessary to achieve their care goals.

• Identify and assist participants in obtaining community resources including food assistance, housing support, utility assistance, transportation resources, and other community-based programs.

• Initiate referrals to local agencies and organizations and support participants throughout the application process.

• Work collaboratively with participants and designated representatives to address barriers that impact health, safety, and independence.

• Maintain knowledge of available community resources and eligibility requirements.

• Participate in community meetings and outreach efforts to expand resource networks.

• Assist participants and families with Medicaid and Medicare applications, renewals, and recertifications.

• Support acquisition of Social Security, financial assistance, and other public benefit programs.

• Help participants complete budget information and payment-related documentation.

• Collect and maintain financial verification documents such as Social Security award letters.

• Collaborate with Finance and Social Work teams regarding participant financial obligations and payment arrangements.

• Educate participants and caregivers on services available through PACE and community programs.

• Provide information regarding participant rights, grievance processes, and benefit requirements.

• Assist participants with advance care planning resources, including funeral and burial planning information.

• Ensure participants receive annual acknowledgements and required educational materials.

• Support communication and education in participants' preferred languages whenever possible.

• Work closely with Social Workers and the Interdisciplinary Team (IDT) to support participant-centered care plans.

• Communicate participant needs, challenges, and resource updates to appropriate team members.

• Support social work staff during community visits and participant encounters as needed.

• Provide assistance with Consumer Advisory Council and Participant Council activities.

• Answer participant-related calls and coordinate information with designated team members.

• Maintain accurate, timely, and complete documentation within the electronic health record.

• Protect confidential participant information in compliance with HIPAA and organizational policies.

• Complete and maintain required records, releases of information, and care coordination documents.

• Review documentation for signatures, dates, titles, and required regulatory elements.

• Support audits, quality initiatives, and performance improvement activities.

• Develop partnerships with community agencies and service providers.

• Educate healthcare organizations and community members about PACE services.

• Promote awareness of available resources that support participant independence and quality of life.

• Represent the organization professionally within the community.

• High School diploma or GED required.

• Experience in healthcare, social services, community resources, human services, or a related field required.

• Experience working with adults and older adult populations preferred.

• Knowledge of Medicaid, Medicare, community assistance programs, and public benefits preferred.

• Experience with behavioral health and/or mental health services preferred.

• Strong communication, organization, customer service, and…