Care Coordinator for a Home and Community Based Program

ABOUT THE ORGANIZATION

Wesley Secure Care is a Maryland-based, mission-driven, nonprofit organization dedicated to helping older adults remain in their own homes as they age, through a personalized plan of coordinated support and care so they can thrive with confidence and security. Through our Continuing Care at Home (CCaH) membership program, members receive coordinated home-based services, support with medical appointments, and financial protection that allows them to plan ahead and remain independent as their needs change. Should members eventually require long-term services in their homes or in their choice or available retirement community, assisted living, or nursing home, Wesley Secure Care helps coordinate and pay for these services as well.

Our office is based in Towson, but our positions work between our office, home office, and in the field throughout Maryland.

POSITION SUMMARY

The Care Coordinator at Wesley Secure Care is responsible for delivering high-quality, person-centered care coordination to members enrolled in the Continuing Care at Home program. This role supports older adults in maintaining independence, safety, and well-being in their homes by conducting comprehensive assessments, coordinating services, and developing individualized care plans.

Working closely with members, families, providers, and interdisciplinary team members, the Care Coordinator ensures services are delivered in alignment with Wesley Secure Care’s mission, program standards, and all applicable regulatory requirements. The ideal candidate is compassionate, organized, collaborative, and committed to supporting older adults as they age safely and confidently in place.

KEY RESPONSIBILITIES

Care Coordination & Member Support

1. Conduct initial and ongoing in-home assessments, including functional, psychosocial, cognitive, and environmental evaluations.
2. Perform and document cognitive assessments and monitor for changes in member condition and functioning.
3. Complete quarterly and annual reassessments, or more frequently as needed, to ensure care plans reflect current member needs and preferences.
4. Develop, implement, and update individualized service plans (ISPs) in collaboration with members, families, and the interdisciplinary team.
5. Coordinate and manage home and community-based services, including personal care, therapies, transportation, skilled services, and community resources.
6. Monitor member well-being, service effectiveness, and satisfaction with services provided.
7. Serve as a primary point of contact and advocate for members and families.
8. Assist members during changes in condition, transitions of care, hospitalizations, or crisis situations.
9. Promote wellness, independence, safety, and successful aging in place for all members.
10. Support the Life Plan Counselors in gathering any required medical information promptly and communicating the status of applications as well as any concerns.

Regulatory Compliance & Documentation

1. Ensure all care coordination activities, assessments, and documentation comply with Maryland regulations, Continuing Care at Home standards, and Wesley Secure Care policies and procedures.
2. Maintain accurate, timely, and compliant documentation including assessments, service plans, progress notes, and care coordination records.
3. Participate in quality assurance activities, audits, accreditation reviews, and regulatory reporting as needed.
4. Maintain confidentiality and safeguard sensitive member information in accordance with HIPAA and organizational standards.

Communication & Collaboration

1. Collaboration with physicians, providers, families, community organizations, and interdisciplinary team members to coordinate member care and services.
2. Occaissional participation in interdisciplinary team meetings, case reviews, and organizational planning activities.
3. Provide education and guidance to members and families regarding aging, chronic conditions, community resources, and long-term care planning.
4. Develop and maintain positive relationships with healthcare providers, community partners, and referral sources.
5. Networking with community resources.

QUALIFICATIONS

Required

1. Bachelor’s degree in Social Work, Nursing, Gerontology, Human Services, or a related field.
2. Minimum of two years of experience in care coordination, case management, healthcare, aging services, or a related field.
3. Experience conducting home visits and comprehensive assessments with older adults preferred.
4. Strong written and verbal communication skills with the ability to communicate compassionately and effectively with older adults and families.
5. Strong organizational skills and attention to detail required.
6. Ability to work independently in a field-based role while managing multiple priorities and member needs.
7. Proficiency in Microsoft Office 365 and electronic health record or care management systems.
8. Valid driver’s license, reliable transportation, and willingness to travel throughout Maryland for member visits and meetings. Mileage reimbursed.
9. Commitment to the mission of serving older adults and their families.
10. Familiarity with cognitive screening tools such as MoCA, Mini-Cog, or MMSE.
11. Knowledge of Continuing Care at Home, life care, long-term care planning, or aging services preferred.
12. Experience with care management software and electronic documentation systems.

KEY COMPETENCIES

1. Mission-Driven: Demonstrates genuine care for the well-being of older adults and alignment with the organization’s values.
2. Communication: Communicates clearly, compassionately, and professionally with members, families, providers, and team members.
3. Initiative: Proactively identifies member needs and follows through on care coordination activities.
4. Collaboration: Works effectively as part of a small, mission-focused interdisciplinary team.
5. Adaptability: Comfortable working in a dynamic environment with evolving member and organizational needs.
6. Discretion: Handles sensitive member information with confidentiality and professionalism.
7. Problem Solving: Demonstrates sound judgment and critical thinking in addressing member concerns and care needs.

WORK ENVIRONMENT

This position operates in a professional office and community-based environment located in Towson, Maryland. Hybrid work arrangements may be available. Frequent travel to members’ homes and community locations throughout Maryland is required. Minimal evening and weekend availability may occasionally be necessary.

The employee must be able to occasionally lift and carry up to 25 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

Wesley Secure Care is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

To apply, please submit a resume and cover letter to Catherine.scott@wesleysecurecare.org