Job Details: Job Location: Valir PACE - Shawnee - Shawnee, OK, Position Type: Full Time, Salary Range: Undisclosed, Job Shift: Day, Valir PACE provides integrated medical and social services to our most vulnerable seniors, helping to unlock their full potential. We are looking for team members who are energized by working in diverse teams toward our shared purpose. Those eager to drive groundbreaking innovation, and who will interact with those we serve and those who serve them in a spirit of understanding and compassion.   WHAT WE OFFER Competitive pay, retention and referral bonuses Outstanding Medical, dental, and vision insurance Paid day off for your birthday 401K Company match on day one Company paid life insurance Generous PTO Career development opportunities Employee Recognition   #PACE About the Role: Job Summary:  The position serves as a primary source to coordinate all transitions of care, mental, and psychosocial care as well as counsels participant on financial and advanced care planning options including advanced directives, DNR, etc. Advocates for participants and ensures participants’ wishes are enacted.   Duties/Responsibilities:  Serves as primary point of contact for all transitions of care. Arranges for beds as needed for appropriate level of care (acute, post-acute, hospice, etc), coordinates all necessary team members including PACE IDT, external care providers, pharmacy, transportation, etc.  Finds and obtains access to community resources to support participants and their families. Also organizes caregiver and other appropriate support groups for participants. Identifies resources to meet the psychosocial needs of each participant.  Responsible for providing case management services for patients  Assists participants and families with DNR, Advanced Directives, etc. as needed with an emphasis on ensuring patient’s AD’s are congruent with their disease process. Actively supports participant’s development of end of life plan that is well defined, communicated to family and care team and is in line with participant’s wishes.  Performs annual and bi-annual assessments and status change assessments as indicated by Federal and State regulations.  Performs routine mental health assessments including depression, anxiety and care giver burnout and makes appropriate referral for mental health services and caregiver support as needed.  Provides and recommends participants attendance to appropriate group counseling to support effective mental health hygiene and coping skills for participants.     Facilitates care planning meetings, family meetings, and meetings with other care teams such as nursing home, etc.  Assist with providing escort services to participant appointments when needed to advocate for participant Any and all other duties and responsibilities as assigned.