Dementia Care Navigator: Care Coordination Leader

Bay Aging; Virginia; Hybrid; USD 48,000 - 55,000; Full time

Job summary

Bay Aging in Urbanna, VA is seeking two full-time Dementia Care Navigators to be the primary contact for beneficiaries with dementia and their caregivers. You will manage an assigned caseload, coordinate medical and community-based services, and maintain person-centered care plans under the GUIDe model.

Responsibilities include conducting assessments, home visits, and updates to care plans, coordinating with providers, supporting care transitions, and guiding families to resources while ensuring

Qualifications

• Requires at least an associate or bachelor degree in nursing, social work, human services, gerontology, healthcare, or related field (preferred).
• Two years of care coordination, case management, dementia care, caregiver support, aging services, or related experience is strongly preferred.
• Experience documenting services in electronic records and coordinating with multiple providers is expected.

Responsibilities

• Serve as primary contact for GUIDE beneficiaries and caregivers; manage referrals and caseload.
• Coordinate assessments, home visits, and reassessments for beneficiaries and caregivers.
• Develop, update, and maintain person-centered care plans in electronic health records.
• Complete caregiver contacts based on GUIDE tier; monitor progress toward goals.
• Coordinate care with primary care providers, specialists, and hospitals.
• Support care transitions, appointments, and medication schedules; provide referrals to resources.

Skills

Care coordination

Case management

Assessment

Care planning

Follow-up

HIPAA knowledge

Education

Related degree preferred

Tools

Electronic health records

Microsoft Office

Telehealth platforms

Job description

Bay Aging in Urbanna, VA is seeking two full-time Dementia Care Navigators to be the primary contact for beneficiaries with dementia and their caregivers. You will manage an assigned caseload, coordinate medical and community-based services, and maintain person-centered care plans under the GUIDe model.

Responsibilities include conducting assessments, home visits, and updates to care plans, coordinating with providers, supporting care transitions, and guiding families to resources while ensuring