About Seen Health At Seen Health, we are revolutionizing the way senior care is delivered through the PACE (Programs of All-Inclusive Care for the Elderly) model. Backed by top VCs, Seen Health is a culturally-focused, technology-enabled healthcare organization that integrates comprehensive medical care and social support with a high-touch, interdisciplinary approach. Our mission is to empower seniors to age-in-place with dignity and provide their families peace of mind.

We are building upon a proven Home and community based services model to create a culturally-competent and scalable PACE program. We are also building a comprehensive operating system focused on data and workflows that span across systems, processes, people, and care contexts. We want to empower our clinicians and staff with tools that deliver relevant data at the time and site of care and enable them to deliver exceptional care to our participants, which improve clinical outcomes, participant & provider satisfaction, and ultimately our strength as an organization.

We are a mission-driven, multidisciplinary team with deep healthcare, technology, and operations expertise, each inspired by our own personal stories of caring for seniors in our lives. Our name, Seen Health, was chosen to reflect our commitment to provide the highest standard of care to underserved older adults while respecting and incorporating their individual beliefs, heritage, and values, so that they can truly be seen .

About The Role

Under the supervision of the Clinic RN, the Home Care Coordinator (LVN/RN) provides home-based nursing services under the LVN or RN scope of practice and coordinates home care services that support Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) that are essential for helping PACE participants maintain their independence and quality of life while living at home.

Responsibilities

Performs duties and

in conformance with state and federal regulatory

Requirements

, Seen Health Policy & Procedures , and Quality Improvement and Compliance guidelines. Handle incoming calls related to participant inquiries, primary care provider orders, and referrals, ensuring effective communication with participants, care team members, and external agencies. Home Care Services: Coordinates home care services as assessed by Case Management RN and approved by Primary Care Provider.

Coordinates home care schedules with subcontracted Home Care Services provider. Submits home care request and authorization forms to subcontracted agency. Reviews service confirmation for accuracy and alignment with IDT approved services.

Provides education to participant , caregivers or family members regarding the scope of approved home care services, as indicated on the participant care plan. Serves as the primary contact for contracted agencies regarding referrals, authorizations and scheduling. Maintains complete participant medical records with the timely requisition of home care service records and upload to the participant medical record.

Conducts quality checks ensuring that home care services are rolled out as indicated on participant care plan. Collaborates with Case Management RN to remedy service issues. Provides training to agency caregivers and conducts initial competency assessments prior to subcontracted staff providing direct participant care.

Conducts annual caregiver competency activities. Conducts QI and Utilization Management activities, tracking the effectuation of home care services and assisting with remediation for service interruptions and/or under/over utilization of services. Nursing Services in Home Setting: Performs physical evaluation, including vital signs and blood glucose monitoring in the Home Documents observations of participant's condition during every visit and in patient health record within required timeframes.

Reports changes in condition to Clinic RN Manager and Case Management RN.