Care Navigator

About Us

The agency has been supporting individuals' desires since 1974, focusing on independence and community living. We welcome creativity and foster a stimulating, friendly, and collaborative work environment. We offer competitive salaries, generous benefits, and an excellent work-life balance.

Position Responsibility

The Care Navigator is a core team member responsible for providing continuous, proactive care coordination for people living with dementia (PLWD) and their caregivers. This includes ensuring compliance with CMS GUIDE Model deliverables, conducting assessments, assisting with caregiver needs, coordinating care teams, and connecting PLWD and caregivers to appropriate services.

Essential Functions

• Serve as the primary contact for assigned PLWD and their caregivers, offering consistent care navigation throughout enrollment in the GUIDE Program.
• Conduct and document comprehensive person-centered assessments, including face-to-face in-home visits in accordance with GUIDE Model requirements.
• Aid in initial and ongoing caregiver needs assessments, including caregiver burden, education, respite, and behavioral health needs.
• Cookorate care team meetings and ensure integration of all team members (e.g., primary care providers, behavioral health, specialists, community supports).
• Set up schedule to follow-up to include monthly contacts.
• Ensure timely and accurate documentation of all interactions, care plans, and care transitions.
• Connect PLWD and caregivers to appropriate medical, behavioral, social, legal, and community-based services.
• Monitor and facilitate use of respite care and other CMS-covered GUIDE supports.
• Collaborate with ADRCs, dementia-capable organizations, transportation services, meal programs, and others to support care goals.
• Promote health equity and culturally responsive services for diverse populations.
• Provide dementia education to caregivers tailored to disease stage and individualized needs.
• Offer evidence-based coaching and support for common caregiving challenges (e.g., behavioral symptoms, communication, safety).
• Facilitate access to caregiver training resources and peer support groups as required under GUIDE guidelines.
• Support collection of required CMS data elements, quality metrics, and beneficiary/caregiver feedback.
• Participate in CMS-required training and program fidelity activities.
• Contribute to continuous quality improvement efforts, performance monitoring, and compliance audits.

Qualifications

• Bachelor’s degree in social work, human services, or related field preferred; case management and experience with the older adult population preferred; Associate degree with significant relevant work experience can be substituted for portion of degree.
• Reliable transportation and valid driver's license required as field work is an essential component of the position.
• Understanding of dementia types, progression, and evidence-based support strategies.
• Care Navigator 20-hour training will be provided and is mandatory to complete.
• Strong documentation skills and familiarity with EHR or care management platforms.
• Ability to work independently and as part of an interdisciplinary team.
• Exceptional communication, problem-solving, and cultural competency skills.
• Preferred Certification in dementia care (e.g., Dementia Care Specialist, Positive Approach to Care, Alzheimer's Association).
• Familiarity with CMS GUIDE Model participation or other Innovation Center programs.
• Bilingual skills or lived experience as a caregiver highly valued.

Work Environment

Based in a community-based organization or nonprofit agency serving older adults and caregivers. Role may include hybrid remote work, home visits, telehealth navigation, and community outreach. Occasional evening/weekend hours to accommodate caregiver needs and meet CMS access standards.

Our Commitment to Diversity and Inclusion

We are committed to fostering a professional environment that recognizes, respects, and encourages the unique contributions of a broad spectrum of qualified employees. We maintain a work atmosphere that allows people of varied backgrounds to grow professionally and contribute to our mission by promoting diversity, equity, inclusion, and work-life balance.