GUIDE Care Navigator- Health Services

What You’ll Be Doing

• Conduct targeted outreach to enroll eligible Medicare beneficiaries and maintain ongoing program engagement.
• Complete comprehensive assessments to help build and update individualized care plans for participants and caregivers.
• Conduct clinical medication reviews to identify concerns/barriers; educate caregivers on dementia progression, symptom management, and medication adherence.
• Coordinate medical, behavioral health, social services, home care, transportation, and respite care options.
• Provide support via home visits throughout the service area (Bronx and Westchester), as well as virtually, by phone, or in clinical settings.
• Monitor participant needs, communicate clinical changes promptly to Montefiore/JASA team members, and participate in case conferences and supervision.
• Maintain accurate, timely records in electronic health record (EHR) systems to support quality improvement and program reporting.

What You’ll Need

• Education: International Medical Graduate (IMG) required.
• Language Skills: Must be fluent in both English and Spanish.
• Clinical Expertise: Strong clinical knowledge with the ability to review medications, explain disease progression, and deliver disease management education.
• Fieldwork & Travel: Ability and willingness to conduct home visits throughout the Bronx and Westchester.
• Experience: Experience working with older adults, individuals living with dementia, caregivers, or clients with complex medical/social needs is preferred.
• Technical Skills: Proficiency with Electronic Health Record (EHR) systems and standard computer applications; exceptional documentation and organizational skills.