Grey Matters Health is seeking a dedicated Care Navigator to join our team. The Care Navigator for Grey Matters Health will be responsible for providing total health care management for an eligible population. This position has been created to coordinate the activities for the Guide Program. The Care Navigator (CN) must have the following skills:

• Background on Dementia - Overview of dementia as a medical condition and progression of the disease and balancing dementia with other co-morbidities.
• Overview of Assessments - Create assessments related to dementia and recommendations for a successful assessment of patient needs.
• Implementing Care Plan - Reviewing care plan and working to assist in carrying out the Care Plan created by the caregivers.
• Person-centered Planning - Planning for needs of patient to be successful in managing dementia.
• Challenging Behaviors - Behavioral symptom management and common behavioral changes due to dementia and how to address.

Job Requirements:

The CN will complete care delivery reporting at least once per year, which will consist of a series of questions about how they are implementing the care delivery requirements of the GUIDE Model; including how frequently they are interacting with aligned beneficiaries and their caregivers and what care modalities they are using.

Care delivery reporting will also include a Health Equity Plan section, as discussed in the “Health Equity Strategy” section.

CN will bear primary responsibility for initial drafts of all annual reports due under the GUIDE Model.

Monitoring and assessing for each patient:

• Reviews and understands Care Plans – assist in ensuring success
• Functional Needs – Patient activities of daily living
• Advanced Care Planning – Assisting Patient in advance care planning
• Decision Making Capacity – Capacity for medical decision making
• Safety – Considerations for safety at home, public, driving, elder abuse, neglect, financial exploitation, access to weapons and dangerous substances
• Communication – communication strategies for patient and caregivers
• Coordination of Medical and Community Services – Supporting patient between provider and community partners addressing gaps in services and duplication
• Supporting caregivers – support groups, peer-to-peer support training and education
• Diversity in Dementia – treating dementia and communicating with diverse populations
• Utilizes technology to ensure efficient management of patients and ensures all required reports are completed timely

The Care Navigator must be committed to putting the patient first by understanding the total person, their health risks, their goals and objectives, and work collaboratively with the clinical team and patient and families to engage them in maintaining or improving their brain health and overall health.

Capabilities:

1. Support patients in coordination of care and care plan implementation.

a. Provides educational support

b. Listens to and understands the patient’s values and needs

c. Supports and coordinates goals for each patient to be monitored and tracked

d. Participates in coordinating education sessions among targeted populations with prevalent health risk factors, such as diet and exercise, respite care, etc.

e. Serves as primary link between the GUIDE Model patients and community resources.

2. Behaves in Accordance with Grey Matter’s Mission and Values

3. Schedule - The parties agree Grey Matters shall set the schedule in accordance with the needs of health center patients.

Required Qualifications:

• Registered Nurse Experienced in care management, care management or case management for older adults
• A commitment to working collaboratively with the clinical team and patient to improve their health
• Good leadership skills and communication skills
• Experience with electronic medical records

Job Type: Full-time

Pay: $60,000.00 - $75,000.00 per year

Benefits:

• 401(k)
• Flexible schedule
• Paid sick time
• Paid time off

Medical specialties:

• Geriatrics
• Primary Care
• Public Health

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• In-person

Work Location: In person