Dementia Care Navigator (CHW)

AMG Senior Medical Group; Murray (UT); On-site; USD 29,000 - 32,000; Full time

Job summary

AMG Senior Medical Group in Murray, UT is seeking a Community Health Worker to support the CMS GUIDE model, focusing on outreach, education, care navigation, and administrative tasks for program participation.

The CHW will serve as a primary contact for patients living with dementia and their caregivers, conducting monthly follow-ups, documenting interactions, and coordinating with partner organizations to promote continuity of care.

Qualifications

• Experience in healthcare, social work, public health, or community outreach strongly preferred.
• Familiarity with dementia care, caregiver needs, and health system navigation is an asset.
• Strong communication, organization, and documentation skills.
• Comfort using EHRs, tracking tools, and CMS-aligned documentation systems.
• Ability to work independently while collaborating with interdisciplinary team members.
• Compassionate, patient-centered mindset with a commitment to improving care for aging populations.

Responsibilities

• Perform monthly follow-up calls to enrolled patients and caregivers to assess needs.
• Track and document interactions, caregiver needs, referrals, and service updates in CMS GUIDE records.
• Assist with administrative tasks, including GUIDE visit documentation and billing preparation.
• Collaborate with practice's billing and coding team to ensure GUIDE-related encounters are submitted.
• Coordinate annual assessments, caregiver services, and respite referrals as required.
• Attend GUIDE program meetings and support quality improvement initiatives.
• Serve as liaison between patients, caregivers, providers, and community organizations.
• Prepare GUIDE-related reporting and training materials.

Skills

Healthcare experience

Social work

Public health

Community outreach

Dementia care familiarity

Communication skills

Documentation skills

EHRs

Education

High School Diploma

Tools

EHRs

Job description

AMG Senior Medical Group in Murray, UT is seeking a Community Health Worker to support the CMS GUIDE model, focusing on outreach, education, care navigation, and administrative tasks for program participation.

The CHW will serve as a primary contact for patients living with dementia and their caregivers, conducting monthly follow-ups, documenting interactions, and coordinating with partner organizations to promote continuity of care.