GUIDE CARE NAVIGATOR

AGING & IN-HOME SERVICES, INC.; Fort Wayne (IN); On-site; USD 38,000 - 48,000; Full time

Job summary

Aging & In-Home Services, Inc. is seeking a Care Navigator to support the AIHS GUIDE Clinic.

The role includes screening patient referrals, registering patients, and coordinating with GUIDE Clinical staff to implement care protocols for dementia patients and their caregivers. The position requires strong documentation, coordination, and communication skills, with responsibilities including home visits, teleconferencing, and adherence to HIPAA and program standards.

Qualifications

• High School Diploma or GED required.
• ABC Community-GUIDE Certification will be obtained with support of AIHS GUIDE Program upon hire.
• Community Health Worker Certification may be required (may be obtained with support of AIHS GUIDE Program upon hire).

Responsibilities

• Screen referrals and register patients per GUIDE protocol.
• Conduct caregiver assessments and home visits.
• Maintain GUIDE EMR documentation and communication with the care team.

Education

High School Diploma/GED

ABC Community- GUIDE Certification

Community Health Worker Certification

Job description

Performs all assigned activities to support the AIHS GUIDE Clinic including but not limited to patient referral screening, patient registration, patient rooming, caregiver assessments, ABC Community-GUIDE intervention protocol to achieve program goals, home visits with patient/caregiver, managing satisfaction surveys, etc. The Care Navigator interacts directly with GUIDE participants with dementia and their caregivers to implement care protocols in collaboration with the GUIDE Clinical staff (NP, MD).

Essential Duties/Responsibilities

Develop and maintain an accurate and thorough knowledge of all program requirements

Develop and maintain skillset on tools required to perform job tasks in a timely and accurate manner including specialized computer software

Organize and document daily schedule to inform supervisor of activities, and adhere to safety protocol

Demonstrate competency by meeting or exceeding minimum caseload requirements and department work performance expectations

Develop and maintain knowledge of community resources available to assist patients and caregivers; work with other AIHS departments to acquire knowledge of community resources available.

Develop and maintain knowledge of the CMS GUIDE program requirements and work to ensure all CMS standards are maintained. Report any identified issues immediately to supervisor

Respond in a timely manner to patient and caregivers, community providers and other GUIDE team members needs and requests per deadlines established

Communicate effectively with cognitively impaired patients per training

Participate in team care coordination/case conferences for assigned patients

Conduct the caregiver needs assessments and follow-up visits in patients’ home or by videoconferencing and telephone

Assist the GUIDE care team in monitoring medication adherence

Complete accurate, timely, comprehensive documentation per GUIDE protocol

Utilize GUIDE electronic medical record (EMR) to complete timely and accurate documentation

Complete all assigned training related to dementia and supporting caregivers provided by the AIHS GUIDE Program or outside approved educational providers.

Provide education, training, and coaching to introduce or improve the coping skills of patients and caregivers.

Demonstrate judgment and critical thinking skills in identifying patient’s needs and escalating to the GUIDE care team as required by departmental protocols,

Develop and maintain accurate knowledge of, and monitor compliance with, HIPAA and agency confidentiality policies.

Serve as an example of agency Standard of Excellence by exemplifying agency vision and goals.

Communicate with supervisor on weekly basis, and as needed, to report all areas of concern/issues/incidents.

Demonstrate professionalism in relationships with customer/co-workers/ supervisors to build rapport while refraining from inappropriate familiar personal relationships.

Complete and attest to accuracy of payroll records and submit for review ad processing according to agency schedule.

Other Duties and Responsibilities

• Other duties as assigned.

Required Education and Experience

• High School Diploma/GED required
• ABC Community- GUIDE Certification (will be obtained with support of AIHS GUIDE Program upon hire)
• Community Health Worker Certification may be required (may be obtained with support of AIHS GUIDE Program upon hire)

Preferred Education and Experience

• Associate degree, two years of related experience preferred
• Experience working with older adults preferred
• Prior experience in a healthcare environment preferred

Additional Eligibility Requirements

Must possess and provide annually valid driver’s license and documentation of current automobile insurance at agency-specified levels. Must provide negative TB certificate, or documentation to support exemption, annually. Must comply with requirements of other facilities (hospitals, LTC facilities, etc.) related to flu or other vaccines if job duties require providing services in those facilities.

Expected Hours of Work

This position is non-exempt. Agency business hours are typically Monday through Friday, 8:00am-4:30pm.

Travel

Travel is throughout the agency’s service area during agency business hours.

Physical Demands

The individual must be able to communicate effectively with others and enable understanding by others through communication. The individual is required to sit and/or stand for long periods of time. The individual is required to transport, safeguard, and use a laptop computer and client files. This job is operated in a professional office environment using standard office equipment such as computers, phones, photocopiers, fax machines, etc. This job also operates at clients’ residences.