Case Manager

The Program of All-Inclusive Care for the Elderly (PACE) offers a variety of services, with many of them provided onsite at a PACE Center. PACE is an alternative to nursing home care and – through an interdisciplinary care team (IDT) of physicians, nurse practitioners, nurses, social workers, therapists, van drivers, and aides – coordinates and provides preventive, primary, acute, and long-term care services, so older individuals can continue living in the community.

Senior Care Partners PACE is seeking a compassionate and motivated Case Manager to support older adults in maintaining independence and quality of life. This role is ideal for a social work professional who values collaboration, community-based care, and participant-centered services.

Primary Purpose

• Assist in coordinating social service programs in accordance with PACE regulations and organizational policies

• Support participants, families, and the interdisciplinary team through resource coordination and advocacy

Key Responsibilities

• Conduct home visits based on participant needs

• Provide emotional support to participants to help maintain independence

• Administer assessments and screening tools as required

• Serve as an active member of the Interdisciplinary Team (IDT), collaborating closely with behavioral health

• Communicate participant changes and contribute to care planning and IDT meetings

• Facilitate discussions regarding healthcare wishes and advance directives

• Collaborate with caregivers and IDT to plan, arrange, and monitor respite services

• Refer participants to appropriate community resources and assist with referrals

• Educate and support caregivers and family members

• Provide crisis intervention as needed

• Document services and interactions in the medical record per policy

• Participate in quality improvement activities

• Keep leadership informed of concerns or issues

• Perform other duties as assigned

Qualifications

• Bachelor of Social Work (BSW), licensed in the state of Michigan

• Minimum of one year of experience with frail, elderly, or long-term care populations

• Case management experience required

• Strong collaboration, communication, and problem-solving skills

• Detail-oriented with excellent organizational abilities

• Ability to maintain confidentiality and professional discretion

• Proficiency in MS Office (Word, Outlook, PowerPoint, Excel)

Specific Requirements

• Current CPR certification (or willingness to obtain through Senior Care Partners PACE)

• MoCA certification (or willingness to obtain within 90 days of hire)

• Demonstrated commitment to compassion, integrity, teamwork, and excellence

• Champion of the PACE philosophy and participant-centered care model

• Ability to make independent decisions and deliver exceptional customer service

Work Environment

• Visible presence in the center with frequent interruptions

• Regular communication with staff, participants, caregivers, and community partners

• Occasional work beyond normal hours, including weekends, holidays, and emergencies

• Driving required in all weather conditions

• Possible exposure to communicable diseases and unpredictable home environments

• Must have reliable transportation, current valid Michigan driver’s license and car insurance.
• Must be 18 years of age or older.
• Must be fully vaccinated, or willing to be fully vaccinated against the following communicable diseases: Influenza, MMR, Varicella, Tdap/Td, Covid-19 and Hepatitis B.
• Must be willing to work beyond normal hours and be part of our on-call rotation.