Dementia Care Navigator

Bay Aging; Urbanna (VA); Hybrid; USD 48,000 - 55,000; Full time

Job summary

Bay Aging seeks 2 full-time Dementia Care Navigators to be the primary contact for beneficiaries living with dementia and their caregivers under the GUIDE model. The navigator manages a caseload, coordinates medical and community services, and maintains person-centered care plans across the care continuum.

These roles report to the Community Living Programs Director, require strong care coordination, and involve travel within the Northern Neck and Middle Peninsula.

Qualifications

• 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.

Responsibilities

• Serve as the primary contact for GUIDE beneficiaries and caregivers, managing referrals and caseload.
• Coordinate comprehensive assessments, home visits, and reassessments.
• Develop and share beneficiary-led, person-centered care plans and maintain them in the EHR.
• Manage contacts with beneficiaries and caregivers to monitor progress toward goals.
• Coordinate with providers and community resources, including Medicaid when applicable.
• Provide dementia education, caregiver support, and referrals to trainings and groups.

Skills

Care coordination

Case management

Assessment

Care planning

Communication

Education

Healthcare-related degree preferred

Tools

EHR systems

Microsoft Office

Video conferencing

Job description

Bay Aging is seeking 2 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 PeninsulaESSENTIAL FUNCTIONSServe 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.KNOWLEDGE SKILLS AND ABILITIESStrong 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.Work is performed in an office or remote setting, beneficiaries' homes, healthcare facilities, and community locations. Regular local travel by personal vehicle (mileage reimbursement available) or agency vehicle required. The employee will spend substantial time sitting, standing, walking, speaking, listening, and using a computer. Minimum physical requirements may include the ability to lift 15lbs, walking and climbing stairs.Bay Aging is an Equal Opportunity Employer. All applicants will be considered for employment without discrimination on the basis of race, color, religion, sex, national origin, age, veteran or disability status. Bay Aging is committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. To request reasonable accommodation, contact MaDena DuChemin, Director, Human Resources at [phone], Ext. 1228 or [e-mail] Status: This is an exempt position.Disclaimer: This job description is not designed to cover or contain a comprehensive listing of all activities, duties, or responsibilities required of the employee. From time to time, the supervisor may ask the employee to perform additional duties related to the completion of the work.