Memory Care and Neuroscience Nurse Navigator

Overview

Works collaboratively to identify, design, and deploy best practices for GUIDE and other neuroscience programs.

Responsibilities

• Promote the mission, vision and value of ARH and the neuroscience service line.
• Maintain quality oversight of program and patient care delivery.
• Interpret business data to contribute to decision making.
• Engage with facility and clinic leadership.
• Demonstrate excellent verbal and written communication and interpersonal skills.
• Problem solve and build teams.
• Utilize intermediate features of Microsoft Office products including Outlook, TEAMS, Word, Excel, and PowerPoint.
• Exhibit excellent organizational skills.
• Demonstrate administrative and managerial skills including project management.
• Function independently with simultaneous projects and priorities.
• Adopt an innovative approach to problem solving.
• 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 is present for patients, including comprehensive assessment, home visit, and caregiver assessment.
• Develop comprehensive care plans in conjunction with the interdisciplinary care team.
• Work with ARH internal partners including IT governance / Meditech, ambulatory leadership, revenue cycle, and community development.
• Provide patients and caregivers with informational tools and resources.
• Serve as the primary point of contact for patients and maintain contact frequency per guidelines.
• Coordinate care with primary care providers and other specialists caring for the patient.
• Maintain an inventory of community resources available for patient and caregiver needs.
• Refer patients to community-based services.
• Support patients and caregivers in maintaining medication schedules.
• Administer the caregiver support program including skills training, diagnosis information, support group services, and support calls.
• Arrange respite services as indicated for patients and caregivers.
• Complete required training as outlined by regulatory / CMS standards.
• Educate internal and external partners on available services.
• Attend 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 and health-related social needs.
• Promote 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 the Alzheimer’s Association and Department of Public Health.
• Facilitate support groups.
• Develop and update materials and resources for patients and caregivers.
• Conduct training and information presentations related to the GUIDE and other neuroscience programs.

Qualifications

Education

Minimum Work Experience

Required Skills, Knowledge, and Abilities

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