Clinical Care Navigator

Abode Care Partners

The Care Navigator is a role focused on providing comprehensive care coordination services for individuals living with dementia and their caregivers. Abode Care Partners was accepted into CMS' GUIDE program and this role will be integral to the program's growth and care delivery goals. This position aims to improve the quality of life for these individuals by enabling them to remain in their homes and communities while receiving necessary support and education related to dementia care. Additionally, this person will be tasked with coordinating resources, delivering training, conducting assessments, and developing personalized care plans. As case load allows, this role will also support other high risk patient populations alongside the interdisciplinary care team. Ultimately this person will help us succeed in growing and improving our value-based care model within our highest risk populations.

Along with the Value Based Program Manager and Director of Care Management, builds out the Abode Care Partners GUIDE program; direct responsibilities include caregiver support and education offering, building a rolodex of community resources, including respite care.
• Co-develops patient centered care plan and works collaboratively with care team to adjust when needed.
• Acts as primary point of contact for caregivers, families, and older adults with dementia.
• Actively supports caregivers, families, and older adults with dementia to enhance quality of life and ensure safety in the home.
• Provides education and support around dementia, symptoms, caregiving, and what to expect.
• Screens for unmet care needs including clinical or medication issues, behavioral issues, safety risks, and psychosocial well-being of both caregiver and patient.
• Researches, identifies, and finds connections to local community resources.
• Reconciles medications and assists with medication management strategies.
• Execute quality of life and home safety assessment screening tools to beneficiaries to assess home safety, behavior, function, medication monitoring & support needs, care needs, and advanced care plans.
• Assess and document caregiver concerns including caregiver strain, depression, and poor coping.
• Provide documentation and support general administrative tasks, including managing records, handling correspondence, and adapting to new tasks as they arise.
• Willingness and excited to build something from scratch, rolling up one's sleeves to get the work done, and finding solutions to our challenges.

• Minimum Bachelors degree in Social Work or Nursing with Masters in related field highly preferred.
• 5-7 years experience with complex care coordination and/or population health management.
• Experience with value based care/ACO models.
• Minimally licensed in Ohio as LISW, LSW, or RN with compact license.
• Prefer Ohio resident; KY, Indiana are accepted.
• Highly competent in dementia care of older adults and caregivers.
• Comfortable with technology and performing this role virtually with the potential of some in home (private homes, Assisted Living) visits, pending location.
• Experience building rapport and collaborative relationships with patients, families, community groups, and other provider groups.
• Able to effectively manage difficult patient interactions with empathy and professionalism, even in challenging or emotionally charged situations.