Memory Care and Neuroscience Nurse Navigator

Appalachian Regional Healthcare, Inc.•Lexington, KY

11d

About The Position

Works collaboratively to identify, design, and deploy best practices for GUIDE and other neuroscience programs. This role involves promoting the mission, vision, and values of ARH and the neuroscience service line, maintaining quality oversight of program and patient care delivery, and interpreting business data to contribute to decision-making. The position requires engaging with facility and clinic leadership, problem-solving, team building, and utilizing intermediate Microsoft Office products. Key responsibilities include overseeing daily operations of CMS GUIDE model initiatives, patient care navigation, collaborating with providers and community resources for patient enrollment, ensuring comprehensive documentation, developing care plans, and working with internal ARH partners. The role also involves providing patients and caregivers with informational tools and resources, serving as a primary point of contact, coordinating care, maintaining an inventory of community resources, referring patients to community-based services, supporting medication adherence, administering a caregiver support program, arranging respite services, completing required training, educating partners on available services, staying informed about Alzheimer's/dementia care, developing and maintaining program documentation, promoting the program through various channels, facilitating community engagement, and developing/updating materials for patients and caregivers.

Requirements

Bachelor’s Degree in Nursing preferred with current licensure in KY/WV or compact state
Prior 2-3 years of experience in aging, Alzheimer’s/dementia, patient care navigation or other related field
Excellent written and verbal communication skills
Administrative or managerial experience with ability to oversee projects and multiple priorities
Ability to build collaborative relationships with internal and external customers

Nice To Haves

Leadership and/or program management experience preferred

Responsibilities

Promote the mission, vision and value of ARH and the neuroscience service line
Maintains quality oversight of program and patient care delivery
Interprets business data to contribute to decision making
Works collaboratively to identify, design, and deploy best practices for GUIDE and other neuroscience programs
Engages with facility and clinic leadership
Oversee daily operations of CMS GUIDE model initiatives and patient care navigation
Collaborate with ARH providers and community resources to enroll patients in GUIDE model services
Ensure required documentation present for patients including comprehensive assessment, home visit, caregiver assessment.
Development of comprehensive care plan in conjunction with interdisciplinary care team.
Work with ARH internal partners including IT governance/Meditech, ambulatory leadership, revenue cycle, community development
Provide patient and caregiver with informational tools and resources
Serve as primary point of contact for patient and maintain contact frequency per guidelines
Coordinate care with primary care provider and other specialists caring for the patient
Maintain inventory of community resources available for patient and caregiver needs
Referral of patients to community-based services
Provide patient and caregiver support to maintain medication as scheduled
Administration of caregiver support program including the following: skills training, diagnosis information, support groups services and support calls.
Arrangement of respite services as indicated for patient and caregiver
Complete required training as outlined by regulatory/CMS standards
Education of internal and external partners on available services
Attendance at meetings, workshops or other required trainings
Remain informed about current Alzheimer’s/dementia care and treatments
Help develop and maintain high quality documentation (including EMR) related to the program including quality reporting, health related social needs
Promotion of the program through multiple sources including networking, community outreach, social media and other forms of communication
Facilitate ongoing community engagement programs and work with external agencies, including Alzheimer’s Association and Department of Public Health
Facilitation of support groups
Develop and update materials and resources for patient and caregivers
Conduct training and information presentations related to the GUIDE and other neuroscience programs