Dementia Care Navigator - Cognitive Care (Days)

Support patients and families throughout the course of a dementia diagnosis by coordinating medical, behavioral, and social services, providing education, counseling, and resource navigation, and ensuring impactful, high-quality outcomes and caregiver satisfaction.

Responsibilities

• Serve as the primary navigator for patients diagnosed with dementia and their caregivers.
• Provide education about dementia diagnoses, disease progression, treatment options, and expected care needs.
• Support families in understanding care plans developed by the physician and advanced practice providers (APP).
• Assist families in navigating healthcare systems, specialty services, and community resources, and in identifying unmet social determinants of health and caregiver stressors.
• Provide emotional support and counseling to caregivers and family members.
• Work closely with the physician and APP to support coordinated dementia care.
• Assist in implementing individualized care plans and participate in case management follow-ups or post-visit outreach.
• Coordinate referrals to specialists, therapy services, home health, and community programs.
• Facilitate communication between the care team, patients, caregivers, and outside providers.
• Monitor patient and caregiver needs and identify emerging risks or barriers to care.
• Provide counseling and support to caregivers managing the emotional and practical challenges of dementia care.
• Educate caregivers on behavioral symptom management, safety strategies, and communication techniques.
• Facilitate caregiver support groups or educational sessions when appropriate.
• Connect families with local and national support resources.
• Assist families in accessing community resources such as:
  • Respite care
  • Adult day programs
  • Long-term care planning
  • Transportation services
  • Home safety assessments
  • Legal and financial planning resources
• Coordinate referrals to programs offered by organizations such as the Alzheimer's Association and other community partners.
• Develop a local resource directory for families and assist in building community partnerships.
• Assess risks related to dementia progression, including wandering, medication adherence, and caregiver burnout.
• Adhere to departmental escalation protocols for acute safety concerns.
• Assist families in developing safety plans and contingency care strategies.
• Provide crisis intervention and connect families with urgent support resources when needed.
• Document all patient interactions and care coordination activities in the electronic health record (EHR).
• Track key metrics related to patient engagement, caregiver support, and resource utilization.
• Assist in developing program workflows and best practices for dementia care navigation.
• Participate in interdisciplinary team meetings and case conferences.

Qualifications

Education

• Bachelor’s Degree in Social Work, or an equivalent degree in the social and/or behavioral sciences from an accredited program, or a nursing degree with associated licensure.

Experience

• Minimum of two years in behavioral health and/or eldercare.
• Preferred experience working with geriatric populations.
• Experience in dementia care, behavioral health, or care coordination.
• Knowledge of community resources for older adults and caregivers.

Skills & Competencies

• Strong knowledge of dementia and geriatric care needs.
• Excellent communication and counseling skills.
• Ability to support patients and families during emotionally challenging situations.
• Care coordination and system navigation expertise.
• Cultural sensitivity and patient-centered care approach.
• Strong organizational and documentation skills.
• Ability to collaborate within an interdisciplinary care team.