GUIDE Care Navigator

AgeSpan•Lawrence, MA

21h•$27 - $29•Hybrid

About The Position

Since 1974 our agency has strived towards supporting an individual's desire to make their own decisions, secure their independence and remain living independently in the community. We are proud of our employees who make this possible every day. Our agency is a thought-leader, a nationally known generator of new ideas, because it welcomes creativity, your ideas. It is an outstanding place to work stimulating, friendly, collaborative. We offer competitive salaries, generous vacation time, and an excellent work/life balance. We value diversity and encourage career growth. If you have a passion for improving the lives of the elderly community and enjoy working in a diverse team driven by its mission, you've found the right place! At AgeSpan, you'll find a work environment that combines: A refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds. A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions. Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills. A satisfying balance between your work and personal life, including a flexible workplace, generous paid time off, and wellness programs. Depending on your role and your hours, we offer Flexible schedule and hybrid work opportunities Competitive salaries Healthcare (medical, dental) 403b Retirement Plan with agency match 20 Vacation Days, 12 Sick Days, and 12 Paid Holidays Social Work Licensing Program License Renewal Paid by agency for RN's and Social Workers And MORE! Program Overview: The GUIDE Program (Guiding an Improved Dementia Experience) is a CMS Innovation Center model designed to enhance care coordination, improve quality of life, and reduce caregiver burden for individuals living with dementia. As a community-based care delivery partner, AgeSpan participates in the GUIDE Model by providing structured care navigation, caregiver education and support, and community integration services that align with CMS requirements and person-centered care standards. Position Responsibility: The Care Navigator is a core team member of the GUIDE Interdisciplinary Care Team (ICT) responsible for providing continuous, proactive care coordination for people living with dementia (PLWD) and their caregivers. This position ensures compliance with CMS GUIDE Model deliverables, including development and implementation of person-centered care plans, caregiver needs assessments, connection to community-based services, and documentation of services provided. The Care Navigator serves as a consistent point of contact for enrolled beneficiaries, helping them navigate the complex medical and social systems surrounding dementia care.

Requirements

BA/BS in social work, human services or related field preferred; case management and experience with the older adult population preferred; Associate degree with significant relevant work experience can be substituted for portion of degree.
Reliable transportation and valid driver's license required as field work is an essential component of the position.
Understanding of dementia types, progression, and evidence-based support strategies.
Care Navigator 20-hour training will be provided and is mandatory to complete.
Strong documentation skills and familiarity with EHR or care management platforms.
Ability to work independently and as part of an interdisciplinary team.
Exceptional communication, problem-solving, and cultural competency skills.

Nice To Haves

Certification in dementia care (e.g., Dementia Care Specialist, Positive Approach to Care, Alzheimer's Association).
Familiarity with CMS GUIDE Model participation or other Innovation Center programs.
Bilingual skills or lived experience as a caregiver highly valued.

Responsibilities

Serve as the primary contact for assigned PLWD and their caregivers, offering consistent care navigation throughout enrollment in the GUIDE Program.
Conduct and document comprehensive person-centered assessments, including face-to-face in-home visits in accordance with GUIDE Model requirements.
Assist with initial and ongoing caregiver needs assessments, including caregiver burden, education, respite, and behavioral health needs.
Coordinate care team meetings and ensure integration of all team members (e.g., primary care providers, behavioral health, specialists, community supports).
Set up schedule to follow-up to include monthly contacts.
Ensure timely and accurate documentation of all interactions, care plans, and care transitions.
Connect PLWD and caregivers to appropriate medical, behavioral, social, legal, and community-based services.
Monitor and facilitate use of respite care and other CMS-covered GUIDE supports.
Collaborate with ADRCs, dementia-capable organizations, transportation services, meal programs, and others to support care goals.
Promote health equity and culturally responsive services for diverse populations.
Provide dementia education to caregivers tailored to disease stage and individualized needs.
Offer evidence-based coaching and support for common caregiving challenges (e.g., behavioral symptoms, communication, safety).
Facilitate access to caregiver training resources and peer support groups as required under GUIDE guidelines.
Support collection of required CMS data elements, quality metrics, and beneficiary/caregiver feedback.
Participate in CMS-required training and program fidelity activities.
Contribute to continuous quality improvement efforts, performance monitoring, and compliance audits.
Other duties as indicated and assigned.