Home Care Coordinator

Habitat Health empowers older adults to experience more good days in their homes and communities. Through the Program of All-Inclusive Care for the Elderly (PACE), we provide comprehensive medical care along with support for daily needs such as meals, transportation, and in ‑ home assistance. We deliver coordinated clinical and social care in our centers and directly in participants' homes, creating a fully integrated experience that brings peace of mind and a true sense of belonging. As we expand our scalable, affordable PACE model to meet the growing and complex needs of aging populations, our mission ‑ driven care teams continue to help participants live well on their own terms. Habitat Health is supported by leading healthcare organizations and investors including New Enterprise Associates, Kaiser Permanente, and Town Hall Ventures. We are entering a period of significant growth and are looking for exceptional teammates to help us scale a better model of care for older adults. To learn more, visit Role Scope : We are looking for a Home Care Coordinator to ensure that personal and clinical home care needs are delivered to help our participants thrive. As a member of the Interdisciplinary Team (IDT), the Home Care Coordinator participates in the assessment of participant needs, development of care plans, and coordination of home care services to support safe, effective, and person-centered care in the home setting. Core Responsibilities & Expectations for the Role Exhibit and honor Habitat's values. Conduct comprehensive in-home assessments to evaluate participant care needs, functional status, safety risks, and appropriateness of home care services Perform home safety evaluations and provide recommendations to promote participant independence and reduce risk Assess participants' ability to safely perform tasks and utilize adaptive equipment through observation and return demonstrations Collaborate with participants, caregivers, and family members to identify care needs and service gaps Participate as an active member of the Interdisciplinary Team (IDT) in developing, implementing, and updating participant care plans Partner with clinical and non-clinical team members, including rehabilitation, nutrition, and social services staff, to ensure a comprehensive understanding of participant needs Coordinate home care services to align with the participant's individualized care plan and goals Evaluate completed caregiver tasks and identify services that are frequently declined, missed, or not completed as planned Review weekly home care notes and documentation to identify service gaps, changes in participant condition, Service Determination Requests (SDRs), grievances, and other concerns requiring follow-up or escalation to the appropriate team members. Maintain current and accurate authorizations for home care services, ensuring services are aligned with participant needs and payer requirements Monitor authorization status and coordinate renewals to prevent interruptions in serviceMaintain timely, accurate, and compliant documentation in electronic health records and operational systems Support quality improvement initiatives and compliance activities related to home care services Perform other related duties as assigned Required Qualifications: Minimum of two (2) years of clinical experience, preferably in home care, geriatrics, care coordination, primary care, or a related healthcare setting Knowledge of care planning, clinical assessments, and home care service delivery Ability to conduct comprehensive participant assessments and identify changes in condition or care needs Strong clinical judgment and critical thinking skills Excellent interpersonal, communication, and collaboration skills Ability to work effectively within an interdisciplinary team environment Strong organizational skills with the ability to manage multiple priorities and deadlines Proficiency with electronic health records and healthcare documentation systems Valid driver's license, reliable transportation, and active auto insurance in accordance with state requirements Demonstrates ability to use motivational interviewing, trust building techniques, and clear expectation setting to support acceptance of clinically appropriate home care hours and care recommendations. Preferred Qualifications: Active Licensed Vocational Nurse (LVN) license in the applicable state Experience working with older adult populations Experience in PACE, home health, home care, or managed care environments Bilingual: Spanish/Mandarin/Cantonese preferred. Experience with care coordination, utilization management, or authorization processes preferred Essential Functions & Physical Requirements The following statements describe the general nature of work and physical expectations common across roles at Habitat Health. Specific responsibilities may vary by position. Reasonable accommodations may be made to e #J-18808-Ljbffr