Care Navigator/Case Manager

LifePath Inc.•Greenfield, MA

13h

About The Position

The Care Navigator/Case Manager works with older adults and their care partners, with a specialization in dementia care, to provide comprehensive care management and care coordination services. This integrated role supports individuals in maintaining independence and quality of life through person-centered planning, service coordination, advocacy, and ongoing support. The Care Navigator serves as a consistent point of contact for GUIDE enrolled participants, helping them navigate the complex medical and social systems surrounding dementia care. In addition, the position assists other departments in the agency depending on caseload and need. Located in Greenfield with required home visits in Franklin County and the North Quabbin area.

Requirements

BA/BS in social work, human services or related field preferred with case management and experience with the older adult population preferred; Associate degree with significant relevant work experience can be substituted forportionof degree.
Knowledge of Dementia Care preferred.Care Navigator 20-hour training will be provided and is mandatory to complete.
Understandingdementia types, progression, and evidence-based support strategies.
Strong documentation skills and familiarity with electronic health records (EHR) or care management platforms.
Ability to work independently and as part of an interdisciplinary team.
Exceptional interpersonal and communication skills
Capacity to complete comprehensive needs assessments using observation, listening, and interviewing skills.
Ability to solve problems and find solutions.
Flexible and able to meet multiple, and changing, program demands.
Familiarity with or willingness to learn about health and human services programs.
Displays cultural humility and cultural responsiveness.
Must have a valid driver's license and insured, reliable vehicle and be willing to travel throughout the service area.
Must be available to work between the hours of 9:00 a.m. and 5:00 p.m. and to work inthe event of an emergency during off hours.

Responsibilities

Conduct comprehensive, person-centered assessments with consumers, persons living with dementia, and caregivers, including required in-home visits.
Develop, implement, and update individualized service and care plans in collaboration with consumers, caregivers, formal providers, and informal supports.
Serve as the primary point of contact and care navigator for assigned consumers and caregivers throughout enrollment and service delivery.
Assess caregiver needs, including burden, education, respite, and behavioral health supports.
Coordinate care with internal programs and external medical, behavioral health, and community-based providers.
Authorize internally funded services and monitor service utilization, including respite and GUIDE-covered supports.
Connect consumers and caregivers to appropriate medical, social, legal, and community resources and supports.
Facilitate interdisciplinary team meetings, care conferences, and ongoing communication among care team members.
Provide dementia education, evidence-based coaching, advocacy, and problem-solving support individually and in groups.
Maintain accurate, timely, and compliant documentation in required databases and care management systems in accordance with AGE and CMS GUIDE requirements.
Schedule and conduct regular follow-up contacts, reassessments, and annual re-determinations as required.
Participate in staff meetings, trainings, quality improvement activities, and other duties as assigned, including office and on-call coverage as needed.