Dementia Care Navigator (47870)

Bay Aging•Urbanna, VA

About The Position

Bay Aging is seeking two full-time Dementia Care Navigators to serve as the primary point of contact for beneficiaries living with dementia and their caregivers under the CMS Guiding an Improved Dementia Experience (GUIDE) Model. The navigator manages an assigned caseload, coordinates medical and community-based services, maintains person-centered care plans, and provides caregiver support. The role reports to the Community Living Programs Director or designee. The position serves beneficiaries and caregivers across the Northern Neck and Middle Peninsula. Work takes place in an office or remote setting, beneficiaries’ homes, healthcare facilities, and community locations, with regular local travel. The role is exempt and pays $48,000–$55,000 per year.

Requirements

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.
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.
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.
Ability to meet minimum physical requirements, which may include lifting 15 pounds and walking and climbing stairs.

Nice To Haves

Associate or bachelor’s degree in nursing, social work, human services, gerontology, healthcare, or a related field; relevant experience may substitute for education.
At least two years of experience in care coordination, case management, dementia care, caregiver support, healthcare, aging services, or community-based services.
Experience managing a caseload, completing assessments and care plans, and documenting services in an electronic record.

Responsibilities

Serve as the primary contact for assigned GUIDE beneficiaries and caregivers, manage referrals, and maintain 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 maintain them in the electronic health record.
Complete required beneficiary and caregiver contacts based on the assigned GUIDE tier, in person, by telephone, or by video.
Monitor needs, progress, and changes in condition; 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 and caregiver support, and refer caregivers 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, including support groups, Memory Cafés, and other community engagement activities.
Perform other duties related to completion of the work as assigned.