Dementia Care Navigator

Dementia Care Navigator

Bay Aging is seeking two full-time Dementia Care Navigators to be the primary point of contact for beneficiaries living with dementia and their caregivers. The Care Navigator manages an assigned caseload, coordinates medical and community-based services, maintains person-centered care plans, and provides caregiver support under the CMS Guiding an Improved Dementia Experience (GUIDE) Model. This position reports to the Community Living Programs Director or designee.

Salary $48,000/yr-$55,000/yr.

Location:

Northern Neck and Middle Peninsula

• Serve as the primary contact for assigned GUIDE beneficiaries and caregivers and manage referrals and an assigned caseload.
• Coordinate comprehensive assessments, required home visits, and annual reassessments for beneficiaries and caregivers.
• Develop, update, and share beneficiary-led person-centered care plans and ensure they are maintained in the electronic health record.
• Complete required contacts with beneficiaries and caregivers based on the assigned GUIDE tier to monitor progress toward goals. Contacts may be in person, by telephone, or by video.
• Monitor needs, progress, and changes in condition and report clinical, safety, caregiver, or service concerns to the appropriate team member.
• Coordinate care with primary care providers, specialists, hospitals, pharmacies, and other healthcare providers.
• Support care transitions, medical appointments, referrals, follow-up instructions, and medication schedules.
• Connect beneficiaries and caregivers with community resources and coordinate with Medicaid and other case managers when applicable.
• Provide dementia education, caregiver support, and referrals to skills training, support groups, and other services.
• Coordinate GUIDE respite services and follow up on referrals and service delivery.
• Communicate regularly with the interdisciplinary care team and support access to the program's 24/7 help line.
• Complete assessments, care plans, case notes, referrals, and required program documentation accurately and on time.
• Maintain confidentiality and comply with HIPAA, CMS GUIDE requirements, agency policies, and quality standards.
• Participate in team meetings, care conferences, training, quality improvement activities, and audits.
• Develop and coordinate dementia care programs to include support groups, Memory Cafés, and other community engagement activities.
• Perform other duties related to the completion of the work as assigned.

• Strong care coordination, case management, assessment, care planning, and follow-up skills.
• Knowledge of dementia, caregiver needs, safety concerns, and community resources.
• Ability to communicate effectively with people living with dementia, caregivers, healthcare providers, and community partners.
• Ability to develop care plans and maintain accurate, timely case notes and program records.
• Ability to recognize changes in condition, caregiver concerns, and urgent safety issues and follow established reporting procedures.
• Ability to manage a caseload, organize priorities, and meet required deadlines.
• Ability to work effectively with people of diverse backgrounds in a culturally competent and sensitive manner.
• Knowledge of HIPAA, confidentiality, professional boundaries, and documentation standards.
• Proficiency with electronic health records, care management systems, Microsoft Office, and virtual communication platforms.

• Associate or bachelor's degree in nursing, social work, human services, gerontology, healthcare, or a related field is strongly preferred. Relevant experience may substitute for education.
• At least two years of care coordination, case management, dementia care, caregiver support, healthcare, aging services, or community-based services experience is strongly preferred.
• Experience managing a caseload, completing assessments and care plans, and documenting services in an electronic record is preferred.
• Must complete the required 20-hour GUIDE Care Navigator training before providing GUIDE services and at least two hours of additional training each year.
• Valid driver's license, reliable transportation, and ability to travel throughout the assigned service area are required.