Care Navigator

Salary Range: $ 75,000 To $90,000 Per Year

Summary

The Care Navigator provides residents with compassionate support and expert guidance to foster their optimal well-being and quality of life. This includes assessments, planning, collaboration and facilitation of support, resources, and services for residents. This position works closely with cross functional teams to ensure residents meet the Conditions of Occupancy and thrive safely in community. The Care Navigator aligns with our core company values: Caring, Collaboration, Innovation, Integrity, Respect, Stewardship and Trust.

Essential Job Duties

• Connects new residents to the Horizon House community to establish rapport and outline the wide range of services available within the community and from external partners including, but not limited to, health care and support groups.

• Ensures new residents are familiar with safety measures including pendants and sensor motion monitor in apartment.

• Collaborates with residents to assess, evaluate, plan, implement, and document support and needed resources both from within the community and external partners including home care, mental health services, and case management firms.

• Works with residents to ensure necessary paperwork and contacts, such as the Vial of Life, POLST, DPOA and Executor information, is accurate and up to date.

• Serve as a backup to support Assisted Living residents with mental health or emotional well-being needs.

• Collaborates with cross functional teams to learn about residents being served and how they can best be supported within the community to thrive and remain safe.

• Assure prudent utilization of identified resources by evaluating the options available and balancing cost and quality to assure the optimal well-being and financial outcomes.

• Counsel residents and families in the community on issues of transition and end of life choices, ethical concerns, powers of attorney, and guardianship. Serve as a resource and referral in these areas for complex, technical, or legal questions.

• Respects, honors, and supports resident end of life choices which may include exercising their right, if qualified, for Death with Dignity or Voluntarily Stopping Eating and Drinking.

• Manage the continuum of care with KPI metrics and create monthly reports.

• Responsible for working with prospective Assisted Living (AL) resident/DPOA and AL Social Worker to coordinate financial screen and admission process for transition to AL.

• Supports residents relocating to Assisted Living from Independent Living (IL) and works closely with the AL Team to ensure a smooth transition.

• Collaborates with the Assisted Living Team for transitions of short-term stay residents back to Independent Living (IL) to ensure residents have applicable support services in place and can meet the Conditions of Occupancy.

• Provides relevant input to Assisted Living resident assessments based on knowledge of resident. Collaborates with interdepartmental team members on resident and program needs in the community.

• Collaborates with Community Engagement Manager on relevant referrals and opportunities for applicable shared community outreach.

• Networks and fosters relationships with outside educational and resource entities that relate to issues of aging, mental health, and allied services.

• Prepares and presents on topics of importance to residents and staff.

• Understands the balance between representing resident concerns and the mission of the organization.

• Establishes relationships with hospital and skilled nursing facility partner discharge planners and follows up on residents in these care settings to confirm discharge plans and alignment with Conditions of Occupancy for a return to Independent Living.

• Lives the vision, mission, and values of Horizon House.

• Represents Horizon House in a positive and professional manner.

Secondary Job Duties

• Participates in community task forces and/or meetings upon request by supervisor.

• Ongoing education and training, relevant to the work, and participates in networking opportunities with allied professionals in the field.

• In collaboration with supervisor, identifies opportunities for programs and/or services to meet the emerging and evolving needs of residents and/or other projects as assigned.

• Complete other duties and projects as assigned by management.

Essential Experience/Knowledge/Education/Specialized Training

• Bachelors or Masters Degree in Social Work or Occupational Therapy from an accredited institution or a minimum of five years experience as a Certified Geriatric Case Manager.

• Understanding and experience in working with older adults, dementia, aging issues, complex family dynamics and transition plans.

• Familiarity with Assisted Living and interdisciplinary team approach, knowledge of community services and programs. (preferred)

• Minimum three years experience in serving older adults in a community-based setting.

• Working knowledge of Window's based computer systems and Microsoft office products.

Confidentiality Requirements

Employee accesses, uses and/or discloses Protected Health Information, as defined by HIPAA, only to the extent minimally necessary to accomplish essential job functions. Employee practices appropriate safeguards to prevent unauthorized access, use and/or disclosure of PHR (paper, electronic and oral) within his/her work area.