PACE Care Navigator

Job Description

Job Description

This position is not a remote role

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.

About PACE

Philanthropists Gary and Mary West founded West Health with the mission of enabling seniors to successfully age in place with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life, and independence.

The Gary and Mary West PACE (Program of All-inclusive Care for the Elderly), affiliated with West Health ( is a non-profit that delivers medical, social, and behavioral services to the frail elderly to the North County of San Diego. This PACE center is entrepreneurial in nature and focuses on innovations and bringing new processes to the traditional PACE environment.

We're looking for passionate healthcare providers who want to be part of a team dedicated to enable seniors to live in their communities as independently as possible by providing compassionate, comprehensive health and supportive care.

Position Summary:

Under the direction of the Center Manager, the PACE Care Navigator is responsible for supporting the IDT by coordinating the Service Delivery Request process and documenting the meeting discussions. As an integral member of the Retention Committee, the Care Navigator also provides direct assistance to participants by connecting them to PACE system of care and proactively reaches out to participants to resolve concerns to prevent disenrollment. Communicates appropriately to the interdisciplinary team members, management, and participants to resolve concerns. Promotes professional working relationships with both internal and external customers. Adheres to and supports all organizational policies and procedures and standards.

Essential Functions:

• Participate in IDT meetings and provide support to the IDT.
• Scribes IDT meeting agenda for each pride and assists with coordinating meeting.
• Coordinates transportation schedule in IDT and tracks cancellations.
• Manages Service Delivery Requests to include initiation in EMR, documentation, NOA letters for denials, and service provided dates.
• Collaborates with medical assistant scheduler for centralized assessment and transportation scheduling.
• Leads Retention Committee and acts as a liaison between different disciplines, services, and participants to ensure continuity of care and services.
• Interfaces directly with participants identified as being at risk for disenrollment from the program.
• Clarifies areas of need, available resources, and sources of support, and develops a plan in collaboration with IDT members and the participants, participants families/caregivers.
• Facilitates communication among service providers, family, participants, caregivers.
• Maintains courteous, helpful, and professional behavior on the job.
• Supports the success of the entire IDT team by promoting a collaborative work environment.

Other Functions:

• Special projects including implementation of satisfaction surveys.
• Consistently contributes to problem-solving and cooperates with identified resolutions.
• Brings issues and process improvement ideas to the attention of the Supervisor.
• Maintains verbal and written skills required for the position.
• Attends meetings and participates in committees as required.
• Adheres to all GMWP Policies and Procedures, GMWP Safety Policies and Procedures and OSHA safety guidelines.
• Communicates clearly and concisely with sensitivity to the needs of others.

Education and Certification:

• High school diploma or GED equivalent required.
• Bachelor's Degree in health or human services, preferred.
• Active driver license.
• Clean driving record.
• Proof of auto insurance.

Skills & Experience:

• Two years of health care experience working with frail and/or chronically ill elderly population.
• Knowledge of community resources available to seniors and their families.
• Experience in providing case management services, including motivational and/or clinical interviewing skills.
• Must have excellent written and verbal communication skills and demonstrate the ability to interact clearly and effectively with both internal and external customers.

• Must submit to and pass a pre-employment drug/alcohol screening and criminal background check.
• Must have a current California Driver's License and driving record must be in compliance with Company policy. Must maintain current automobile insurance.
• Proficient in Microsoft Word and Excel.
• CRM and EMR experience preferred.
• Skilled in establishing and maintaining effective working relationships with participants, co-workers, vendors, medical staff, and the public.

Medical Clearance:

Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.

Job offers are contingent upon a successful pre-employment drug screen, background check, and physical assessment.

Gary and Mary West PACE provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, pregnancy, military and veteran status, age, physical and mental disability, genetic characteristics, gender, gender identity, gender expression or sexual orientation or any other considerations made unlawful by applicable state or local laws.