Dementia Care Navigator, Social Worker

Position Overview

As a GUIDE Model Dementia Care Navigator
, you will assist in delivering the 9 core elements outlined in the CMMI GUIDE Model of care delivery. You will build strong, collaborative relationships with internal teams as well as external partners to ensure patients and caregivers receive appropriate and high quality care. Assessment, care planning, coordination of care and resources, and transitional care management are foundational to the position.

The Care Navigator position allows for great work-life balance, with approximately 20% remote and 80% of the time allowing you to directly impact patients, team members and community partners.

Schedule:

Full-time position, day shift hours, no evenings, weekends or holidays. Hours are 8am to 5pm Monday through Thursday & 8am to 3pm on Fridays.

Location:

This position entails a mix of remote work, as well as about 80% direct patient care mainly throughout Tampa, Brandon, Temple Terrace areas.

Salary Range: $65,000 - $80,000, salary will be commensurate with experience.

• Conduct comprehensive assessments including clinical, behavioral, psychosocial, and advance care planning domains
• Review current health needs, identify goals, and develop individualized care plans
• Help connect members with resources and services
• Complete required documentation
• Collaborate with primary care teams to ensure high quality team-based care
• Utilize utilization management tools to facilitate appropriate transitional care management
• Collaborate with hospitals, rehabs, and SNFs to manage inpatient stays and discharge plans
• Communicate effectively with internal and external stakeholders to promote Bluestone’s core values
• Help reduce unnecessary visits to emergency departments and acute settings to lower utilization and costs
• Increase coordination of care for a complex geriatric population
• Be proficient in community resources
• Proactively engage with providers to identify high-risk patients

Education/Certification/Experience

• Degree in Social Work, Licensed Social Worker or Registered Nurse
• 3-5 years of experience in case/care management or care coordination
• Experience working directly with the dementia population required
• Formal training in dementia from a credible organization (e.g., Dementia Practitioner certification) is highly sought
• Valid driver’s license required

Knowledge/Skills/Abilities

• Ability to work independently
• Strong customer service, relationship-building, and communication skills
• Strong technical skills and experience with EHRs preferred
• Demonstrated compatibility with Bluestone’s purpose, focus and values
• Ability to travel throughout the market area as needed
• Proficiency in reading, writing, speaking, and understanding English

Bluestone Physician Services delivers great outcomes by bringing exceptional care to patients living with complex, chronic conditions and disabilities. Our multidisciplinary care teams collaborate with patients, their families and other healthcare providers to deliver care that is preventative, proactive and tailored to their unique needs. Using an evidence-based approach focused on quality care management and data-driven medical decisions, Bluestone care teams manage chronic conditions, address social determinants of health, and support transitions to and from inpatient settings with behavioral health considerations.

• Health Insurance
• Dental Insurance
• Vision Insurance
• Company paid Life Insurance
• Company paid Short and Long-term Disability
• Health Savings Account (with employer contribution)
• Flexible Spending Account (FSA)
• Retirement plan with 4% matching contributions
• Eight paid holidays plus two floating holidays
• PTO (three weeks / 15 days)
• Mileage reimbursement for field employees
• Company sponsored cell phone, laptop and scrubs
• Regular business hours