CARE COORDINATOR, DEMENTIA SERVICES

MissionHires is seeking a Care Coordinator, Dementia Services to support individuals living with dementia and their caregivers through the NaviGuide Program, aligned with Medicare’s Guiding an Improved Dementia Experience (GUIDE) Model. This full-time, remote/field-based role manages a growing caseload, conducts initial in-home assessments, develops person-centered care plans, performs monthly check-ins, coordinates services, and ensures accurate, timely, and compliant documentation. Ideal candidates bring deep dementia-care experience, strong caseload management, and the ability to build trusted relationships with clients, caregivers, providers, and community partners. CARE COORDINATOR, DEMENTIA SERVICES
NaviGuide Program

The Care Coordinator, Dementia Services supports individuals living with dementia and their caregivers through United Church Homes’ NaviGuide Program, delivered in accordance with the Medicare Guiding an Improved Dementia Experience (GUIDE) Model.

Position Summary

The GUIDE Care Coordinator: Dementia Services manages a caseload of individuals living with dementia and provides ongoing education, care coordination, and support to their caregivers. The coordinator conducts initial in-home assessments, develops and maintains person-centered care plans, completes monthly check-ins, connects clients and caregivers with appropriate services, and maintains timely and accurate documentation required by the Medicare Guiding an Improved Dementia Experience (GUIDE) Model.

The current caseload is approximately 25 active clients and is expected to grow to approximately 60–80. After the initial in-home assessment, approximately 95% of ongoing care coordination is completed remotely by telephone, email, and other approved communication methods.

This position is ideal for a highly independent and organized professional who brings deep dementia-care experience, manages competing priorities with confidence, and builds trusted relationships with individuals, caregivers, providers, and community partners.

Essential Responsibilities

·     Manage an active GUIDE caseload expected to grow from approximately 25 to 60–80 clients.

·     Conduct initial in-home assessments and complete required GUIDE assessment tools, including FAST, ZBI-22, PROMIS-10, HRSN, and the comprehensive assessment, in accordance with program protocols and training.

·     Develop, implement, monitor, and update person-centered care plans as client and caregiver needs change.

·     Complete monthly check-ins and provide responsive ongoing care coordination by telephone, email, and in-person visits when needed.

·     Educate individuals and caregivers about dementia, available resources, supportive services, and practical strategies that promote independence, dignity, safety, connection, and quality of life.

·     Serve as a liaison among individuals, caregivers, primary care providers, the GUIDE interdisciplinary team, community agencies, and service providers.

·     Identify changes in client or caregiver needs and make timely referrals to appropriate community-based services and supports.

·     Maintain complete, accurate, and timely documentation in the electronic medical record, including assessments, care plans, referrals, progress notes, and client, caregiver, and provider communications.

·     Meet all Medicare GUIDE documentation, reporting, privacy, quality, and compliance requirements within established timeframes.

·     Independently plan and prioritize caseload activity, follow-up responsibilities, assessments, home visits, and required reporting.

·     Maintain current knowledge of aging, dementia, caregiver support, benefits, healthcare, and home- and community-based resources.

·     Coordinate or support educational programs for individuals, caregivers, staff, and community partners.

·     Perform other related duties as assigned.

Required Qualifications

·     Five or more years of care-coordination, case-management, or service-coordination experience supporting older adults.

·     Five or more years of direct experience working with individuals living with dementia and their caregivers.

·     Demonstrated knowledge of dementia-related needs, caregiver challenges, and community-based supports.

·     Experience independently managing a caseload and maintaining detailed documentation in an electronic medical record or comparable case-management system.

·     Strong organization, time-management, problem-solving, communication, and relationship-building skills.

·     Ability to interpret and follow Medicare program requirements, documentation standards, policies, and deadlines.

·     Ability and willingness to conduct home visits throughout the assigned service area, including during variable weather conditions.

·     Valid driver’s license, acceptable driving record, and ability to meet organizational driving requirements.

Preferred Qualifications

·     Associate or bachelor’s degree in nursing, social work, gerontology, human services, or a related field.

·     Experience working within Medicare, the GUIDE Model, healthcare case management, or another regulated care-delivery program.

·     Certified Dementia Practitioner credential or comparable dementia-focused education or certification.

·     Experience conducting standardized assessments and developing person-centered care plans.

·     Familiarity with community resources and aging services providers in Central Ohio.

Core Competencies

·         Compassionate dementia and caregiver support

·         Independent judgment and accountability

·         Caseload organization and time management

·         Accurate, timely, and compliant documentation

·         Person-centered assessment and care planning

·         Clear written and verbal communication

·         Resourcefulness, advocacy, and collaboration

·         Professional boundaries, discretion, and integrity

Work Arrangement and Travel

This is a remote/field-based position. Initial client enrollment requires an in-person assessment in the client’s home. After enrollment, approximately 95% of ongoing coordination is expected to occur remotely, although additional home or community visits may be required based on client needs, program requirements, trainings, conferences, or organizational events. A company vehicle is anticipated as part of the package; final vehicle and travel details will be confirmed during the hiring process.

Physical and Work Environment Requirements

The position requires frequent sitting and computer use; occasional standing, walking, bending, reaching, kneeling, climbing, and manual manipulation; and occasional lifting or carrying of up to 20 pounds. The employee must be able to travel safely to private homes and community settings and work in varied home environments. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Equal Employment Opportunity

United Church Homes is committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable law.

• Manage an active GUIDE caseload growing from 25 to 60–80 clients

• Conduct initial in-home assessments and complete GUIDE assessment tools (FAST, ZBI-22, PROMIS-10, HRSN, comprehensive assessment)

• Develop, implement, monitor, and update person-centered care plans

• Perform monthly check-ins and provide ongoing care coordination primarily via phone/email, with in-person visits as needed

• Educate individuals and caregivers on dementia, resources, and practical strategies that support independence, dignity, safety, connection, and quality of life

• Serve as liaison among individuals, caregivers, primary care providers, the GUIDE interdisciplinary team, community agencies, and service providers

• Identify changing needs and make timely referrals to appropriate community-based services and supports

• Maintain complete, accurate, and timely documentation in the electronic medical record, including assessments, care plans, referrals, progress notes, and communications

• Meet all Medicare GUIDE documentation, reporting, privacy, quality, and compliance requirements within established timeframes

• Independently plan and prioritize caseload activity, follow-ups, assessments, home visits, and required reporting

• Maintain current knowledge of aging, dementia, caregiver support, benefits, healthcare, and home- and community-based resources

• Coordinate or support educational programs for individuals, caregivers, staff, and community partners

• Perform other related duties as assigned

• Five or more years of care coordination, case management, or service coordination experience supporting older adults
• Five or more years of direct experience with individuals living with dementia and their caregivers
• Demonstrated knowledge of dementia-related needs, caregiver challenges, and community-based supports
• Proven experience independently managing a caseload and documenting in an EMR or comparable case-management system
• Strong organization, time management, problem solving, communication, and relationship-building skills
• Ability to interpret and follow Medicare program requirements, documentation standards, policies, and deadlines
• Ability and willingness to conduct home visits across the assigned service area, including in variable weather
• Valid driver’s license, acceptable driving record, and ability to meet organizational driving requirements
• Preferred: Associate or bachelor’s degree in nursing, social work, gerontology, human services, or related field
• Preferred: Experience with Medicare, the GUIDE Model, healthcare case management, or other regulated care-delivery programs
• Preferred: Certified Dementia Practitioner credential or comparable dementia-focused education/certification
• Preferred: Experience conducting standardized assessments and developing person-centered care plans
• Preferred: Familiarity with community resources and aging services providers in Central Ohio
• Work model: Remote/field-based; initial in-home enrollment assessments required; ~95% of ongoing coordination conducted remotely
• Physical: Frequent sitting/computer use; occasional standing, walking, bending, reaching, kneeling, climbing, and lifting up to 20 lbs; ability to travel to private homes and community settings