Home Care Coordinator / Registered Nurse (RN)

Job Summary 

Under the direct supervision of the Clinic Coordinator, responsible for the development and implementation of homecare services for program participants, including the coordination of all contracted home services, durable medical equipment and nursing home care.


Education and Special Training:  Graduate of accredited school of nursing.

Experience:  At least one year as an RN, preferably in either home or community health.  At least 1 year experience working with the frail or elderly population.

Licensure, Registry or Certification Required:  Currently licensed as RN in North Carolina; valid NC driver’s license and vehicle.

Knowledge, Skills, and Abilities: Must be able to work effectively in a team environment.  Must be able to treat geriatrics. Home Health experience required. Only act within the scope of his or her authority to practice.  Meet a standardized set of competencies established by PACE of Guilford and Rockingham Counties and approved by Centers for Medicare and Medicaid services before working independently.

With or without reasonable accommodations; Ability to bend and or stoop frequently.  Have independent mobility in order to climb stairs and walk distances.  Lift and position patients of all weights and heights utilizing correct body mechanics.  Lift and carry pieces of durable medical equipment.  Lift and transport at least 50 pounds during the course of providing care, treatment and or services.  Utilize correct body mechanics to transfer, lift and position participants.  Read, write and speak in English.  Communicate effectively both orally and in writing.  Ability to clearly see medical records and various documents.  Communicate via telephone.  Hear blood pressures and spoken communication.  Ability to perform repetitive hand/wrist movements.

Key Responsibilities  

  • Assess, using the nursing process, the home care needs of a frail elderly population. Identifies areas of strengths and weakness and develops specific plans of care.  Initial and periodic assessments to be conducted minimally every 6 months and must be completed prior to the scheduled team meeting.  Communicates participant changes with team members.
  • Coordination of 24 hour care delivery and the implementation of all home care services to ensure that quality services are provided to meet participant needs.
  • Coordinated all durable medical equipment authorized by the team. Communicate authorization with accounts payable.
  • Coordinates care delivered to participant in the nursing home/ assisted living, or boarding home according to PACE standards. Interacts with facility staff and documents such.
  • Serves as substitute for Health Care Coordinator as described in North Carolina Adult Day Care and Health Services Standards for Certification.
  • Actively participates in Interdisciplinary Team (IDT) contributing to the participant plan of care. Communicates any changes in participant condition to team members.
  • This position is responsible for on-call supervision of home health aides.
  • On-call rotation as assigned by Clinical Coordinator.
  • Attends staff meetings.
  • Other duties as assigned.

 Environmental Factors

Tasks with potential for exposure to blood borne pathogens include, but are not limited to the following:

  1. Assisting with mouth care
  2. Assisting with care of non-intact skin
  3. Assisting incontinent participants with personal care
  4. Assisting with procedures in the clinic

Demonstrates knowledge of and supports PACE mission, vision, values, standards, policies and procedures, operating instructions, confidentiality standards, and the code of ethical behavior.