Care Navigator – Dementia Care Program, Behavioral Health

Role Overview Avail Health is proud to participate in the CMS GUIDE (Guiding an Improved Dementia Experience) Model, a transformative Medicare program designed to improve quality of life for individuals living with dementia while reducing strain on family caregivers. As a Care Navigator, you will serve as a primary point of contact for beneficiaries and caregivers enrolled in Avail's Dementia Care Program. You will help ensure patients remain engaged, care plans are followed, caregivers receive meaningful support, and barriers to care are identified and addressed before they become crises. Working closely with the GUIDE Practitioner, Licensed Clinical Social Worker, Care Coordinator, and interdisciplinary care team, you will coordinate outreach, follow-up, caregiver support, care plan activities, and program engagement across a highly vulnerable Medicare population. This is a fully remote role that combines care navigation, caregiver support, care coordination, and dementia-focused program management within a technology-enabled virtual care environment. This is a foundational role in a newly launching program. You'll help build the operational workflows, patient engagement strategies, and caregiver support processes that will shape the future of Avail's Dementia Care Program. What You'll Own • Ongoing beneficiary engagement and retention within the CMS GUIDE program • Caregiver outreach, education, support, and navigation • Coordination and follow-through on individualized dementia care plans • Identification and escalation of clinical, psychosocial, behavioral, and safety concerns to the interdisciplinary care team • Accurate, timely, and compliant documentation supporting CMS GUIDE requirements What You'll Do • Serve as a primary point of contact for beneficiaries and caregivers enrolled in the GUIDE program • Conduct proactive outreach and routine follow-up with patients and caregivers to assess needs, support care plan adherence, and identify emerging concerns • Coordinate care plan activities in partnership with the GUIDE Practitioner, Licensed Clinical Social Worker, and interdisciplinary care team • Educate beneficiaries and caregivers on GUIDE program services, dementia-related resources, and available support options including respite care • Conduct caregiver check-ins to assess caregiver burden, stress, support needs, and resource gaps • Identify and escalate concerns related to dementia progression, behavioral symptoms, caregiver capacity, medication management, safety risks, or social isolation • Help identify Social Determinants of Health barriers including transportation, food insecurity, housing instability, and access to community resources • Support care transitions following hospitalizations, emergency department visits, and other significant healthcare events • Coordinate referrals and connect beneficiaries and caregivers to community resources, support programs, and appropriate services • Maintain accurate and timely documentation within the electronic health record and care management systems • Participate in interdisciplinary team huddles, case reviews, workflow improvement initiatives, and program development activities What Success Looks Like • Beneficiaries remain actively engaged in the GUIDE program and receive consistent follow-up support • Caregivers feel informed, supported, and connected to appropriate resources • Care plans are implemented, monitored, and updated according to program requirements • Clinical, psychosocial, behavioral, and safety concerns are identified early and escalated appropriately • Documentation is completed accurately, timely, and in compliance with CMS GUIDE requirements • Strong collaboration exists across the interdisciplinary team • Beneficiary retention, engagement, and program quality metrics consistently meet or exceed program targets What You'll Bring Required: • Associate’s degree or equivalent experience • Minimum 2 years of experience working directly with individuals living with dementia, Alzheimer's disease, or other cognitive impairments • Experience supporting family caregivers, care partners, or complex family systems • Experience in care coordination, care navigation, social services, healthcare support services, community-based programs, or similar patient-facing roles • Experience managing multiple cases, patients, clients, or workstreams simultaneously • Proficiency with EHRs, care management platforms, CRM systems, or similar technology-enabled workflows • Excellent verbal and written communication skills • Strong organizational skills, attention to detail, and ability to manage competing priorities • Reliable high-speed internet connection and dedicated HIPAA-compliant home workspace Preferred: • Associate or Bachelor's degree in Social Work, Human Services, Psychology, Gerontology, Healthcare Administration, or related field • Familiarity with Medicare Advantage, care management, care coordination, value-based care, or population health programs • Familiarity with the CMS GUIDE model or similar dementia-focused care programs • Experience working within startup healthcare organizations or newly launched programs • Experience supporting virtual care delivery or remote care management programs • Bilingual or multilingual communication skills Schedule and Work Style Work Type: Fully remote Schedule: Monday–Friday, standard business hours This role supports beneficiaries and caregivers across multiple U.S. time zones. Candidates must be comfortable managing outreach, follow-up, and caregiver engagement activities throughout the workday to meet patient and program needs. Travel: None required Autonomy: Moderate to high; functions independently while collaborating closely with an interdisciplinary care team Compensation and Perks Salary Range: $65,000–$72,000 annually, commensurate with experience. Key Benefits: • Medical, dental, and vision insurance; 100% employee premium coverage with DPC model • HSA contributions | Life & disability insurance • 401(k) with 2% employer match • 15 days PTO (increasing with tenure) | 8 + 1 floating holidays • Discretionary performance bonus | Annual compensation review • All devices and technology provided About Avail Health Avail Health is a Nurse Practitioner-founded organization delivering mobile and virtual care to Medicare-age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more information, visit www.availhealthcare.co .