Memory Care and Neuroscience Nurse Navigator

Overview

Works collaboratively to identify, design, and deploy best practices for GUIDE and other neuroscience programs.

• Promote the mission, vision and value of ARH and the neuroscience service line
• Maintains quality oversight of program and patient care delivery
• Interprets business data to contribute to decision making
• Works collaboratively to identify, design, and deploy best practices for GUIDE and other neuroscience programs
• Engages with facility and clinic leadership
• Excellent verbal and written communication and interpersonal skills
• The ability to problem solve and build teams
• Ability to use intermediate features of Microsoft Office products including Outlook, TEAMS, Word, Excel, Power Point
• Excellent organizational skills
• Administrative and managerial skills including project management
• Ability to function independently with simultaneous projects and priorities
• Innovative approach to problem solving
• Oversee daily operations of CMS GUIDE model initiatives and patient care navigation
• Collaborate with ARH providers and community resources to enroll patients in GUIDE model services
• Ensure required documentation present for patients including comprehensive assessment, home visit, caregiver assessment
• Development of comprehensive care plan in conjunction with interdisciplinary care team
• Work with ARH internal partners including IT governance/Meditech, ambulatory leadership, revenue cycle, community development
• Provide patient and caregiver with informational tools and resources
• Serve as primary point of contact for patient and maintain contact frequency per guidelines
• Coordinate care with primary care provider and other specialists caring for the patient
• Maintain inventory of community resources available for patient and caregiver needs
• Referral of patients to community-based services
• Provide patient and caregiver support to maintain medication as scheduled
• Administration of caregiver support program including the following: skills training, diagnosis information, support groups services and support calls
• Arrangement of respite services as indicated for patient and caregiver
• Complete required training as outlined by regulatory/CMS standards
• Education of internal and external partners on available services
• Attendance at meetings, workshops or other required trainings
• Remain informed about current Alzheimer’s/dementia care and treatments
• Help develop and maintain high quality documentation (including EMR) related to the program including quality reporting, health related social needs
• Promotion of the program through multiple sources including networking, community outreach, social media and other forms of communication
• Facilitate ongoing community engagement programs and work with external agencies, including Alzheimer’s Association and Department of Public Health
• Facilitation of support groups
• Develop and update materials and resources for patient and caregivers
• Conduct training and information presentations related to the GUIDE and other neuroscience programs

• Bachelor’s Degree in Nursing preferred with current licensure in KY/WV or compact state

• Prior 2-3 years of experience in aging, Alzheimer’s/dementia, patient care navigation or other related field
• Leadership and/or program management experience preferred

• Excellent written and verbal communication skills
• Administrative or managerial experience with ability to oversee projects and multiple priorities
• Ability to build collaborative relationships with internal and external customers