Care Team Specialist (PACE)

Job Description

Job Description

Do you excel at fostering collaboration and accountability within interdisciplinary teams to truly align care with each individual’s unique values and goals? Are you excited about joining a mission-driven organization where your leadership can make a meaningful impact on the quality of life for our participants? Then we would love to have you, on our team!

We’re excited to welcome an experienced and passionate Care Team Specialist to our growing organization. In this vital role, you’ll work closely with our Executive Director and lead an 11-discipline Interdisciplinary Team (IDT) to ensure our participants receive the highest quality care. Your leadership and experience will play a key role in facilitating Interdisciplinary Team Meetings, ensuring we meet all regulatory requirements, and fostering a collaborative, accountable environment that truly aligns with each participant’s values, goals, and preferences.

If you’re driven by a desire to improve the quality of life for others and thrive in a team-centered, mission-driven environment, we’d love to have you join us!

Responsibilities:

• Keep care grounded in the person, not just the plan. Partner with the IDT to identify and act on participants’ goals, values, and preferences, ensuring care plans reflect What Matters Most (WMM).
• Bring Patient Priorities Care to life. Build strong working knowledge of Patient Priorities Care (PPC) and Goal Concordant Care and help embed these principles into everyday practice.
• Lead the conversations that drive great care. Facilitate Care Team Meetings, Care Coordination Meetings, and Care Planning discussions, making sure documentation in the EMR is clear, timely, and accurate.
• Create workflows that make the right thing the easy thing. Develop and maintain care planning, documentation, and compliance workflows aligned with regulatory requirements.
• Be the go-to EMR champion. Serve as an EMR superuser, supporting, guiding, and troubleshooting with team members as needed.
• Keep the team on track and moving forward. Monitor completion of assessments, care plans, service determination requests, trackers, and other IDT deliverables, helping remove barriers when things get stuck.
• Step in when coverage matters most. Act as backup for the Center Manager to help ensure assessments are completed within the required 30-day timeframe.
• Partner for quality you can measure—and feel. Collaborate with Quality Improvement and Compliance to audit care plans and strengthen regulatory alignment.
• Coach with care and accountability. Provide support and supervision that builds confidence, clarity, and follow-through, fostering a culture of ownership and continuous improvement.
• Meet participants where they are—literally and holistically. Support the team in delivering care across settings, with attention to physical, emotional, and spiritual needs.
• Be a team player across the center. Jump in to support other departments when needed (Admin, Home Care, Clinic, and more).
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Actively support the achievement of SCAN’s Vision and Goals. 
• Other duties as assigned.

Qualifications and Experience:

• A mission-first heart for seniors. Genuine passion for serving high-risk seniors and frail older adults.
• Comfort in motion. You thrive in a fast-paced environment and enjoy working in a collaborative, team-based culture.
• A “what matters most” mindset. You naturally center the participant’s goals and help translate them into real, achievable care plans.
• The education and/or licensure to lead confidently. Bachelor’s degree in a relevant field (nursing, social work, healthcare administration, etc.) required; master’s preferred (MSW or healthcare administration). We will also consider an LVN or RN with 5+ years of experience leading an IDT.
• Hands-on care experience. At least 2 years providing direct care (PACE or similar setting strongly preferred).
• Experience in value-based models. 1+ year in a PACE organization or value-based care environment.
• Real IDT fluency. 3+ years of active participation on an Interdisciplinary Care Team.
• Leadership that builds trust and follow-through. Strong communication skills and a proven ability to foster collaboration and hold others accountable with respect.
• A compliance-aware approach. Familiarity with PACE-related regulatory requirements and confidence operating in a highly regulated environment.
• Tech comfort and strong fundamentals. Proficiency in Microsoft Word, Excel, and PowerPoint.
• EMR experience. Prior experience using Electronic Medical Record systems (and the curiosity to become a superuser).

Tuberculosis Screening Policy

To ensure the health and safety of our members, if you are selected for this position, your job offer with SCAN will be contingent on providing proof of Tuberculosis screening upon hire or providing proof of a negative screening within the last year. If you have a disability/medical reason or sincerely held religious belief that prevents you to provide information required in this policy, SCAN will initiate and engage in the interactive process to evaluate what, if any, reasonable accommodations may be available.

What's in it for you?

• Base salary range: $70,300 to $92,602 per year
• Work Mode: Onsite
• An annual employee bonus program
• Medical, Dental, Vision coverage
• Generous paid-time-off (PTO)
• 11 paid holidays per year, plus 1 additional floating holiday
• Excellent 401(k) Retirement Saving Plan with employer match.
• Robust employee recognition program
• Robust Wellness Program
• An opportunity to become part of a team that makes a difference to our members and our community every day!

Through the Program of All-Inclusive Care for the Elderly (PACE), we provide comprehensive, coordinated care, including medical services, therapies, medications, transportation, and nutrition support, all managed by one dedicated team. Instead of navigating multiple doctors and insurance plans, participants receive all-inclusive care designed to help them avoid unnecessary nursing home placement. For eligible individuals, these services are available at no cost.

Company Description

Through the Program of All-Inclusive Care for the Elderly (PACE), we provide comprehensive, coordinated care, including medical services, therapies, medications, transportation, and nutrition support, all managed by one dedicated team. Instead of navigating multiple doctors and insurance plans, participants receive all-inclusive care designed to help them avoid unnecessary nursing home placement. For eligible individuals, these services are available at no cost.