The Care Team Navigator (CTN) (Community Health Worker) is a core member of the Circle of Care: Alzheimer’s & Dementia Resource Center team—a telephone-based program providing support, education, and care coordination for patients with dementia and their caregivers.

The goal of the Circle of Care: Alzheimer’s & Dementia Resource Center is to improve the health and wellbeing of patients with dementia and their caregivers while decreasing unnecessary medical costs. The program supplements primary care and neurology specialty services by providing education, behavioral management support, links to community-based resources, and advance care planning assistance.

The CTN (Community Health Worker) serves as the primary point of contact for patients and families enrolled in the program. CTNs work directly with participants and collaborate with healthcare providers, collaborating with a multidisciplinary clinical team where necessary to support care coordination and service delivery.

Duties/Responsibilities:

• Participate in initial and ongoing training related to neurodegenerative diseases, aging, caregiving, advance care planning, and medication management.
• Maintain and document consistent monthly contact with participants via telephone or email.
• Develop and sustain trusting, supportive relationships with patients and caregivers to foster communication and adherence to care plans.
• Attend weekly in-person and/or virtual debriefing sessions with the programmatic team to review cases, discuss issues, identify resource needs, and develop problem-solving strategies.
• Use integrated workflow management, electronic medical records, and data collection technology to support care delivery.
• Document all communication, interventions, and follow-up activities according to program standards.
• Participate in ongoing evaluation and improvement of the program by contributing feedback during team meetings, surveys, and one-on-one sessions with supervisors.
• Actively participate in initial and ongoing staff training.
• Provide feedback via surveys to help improve intervention.
• Perform day-to-day office tasks such as using the fax machine, sending mail, and general clerical duties.
• Provide standard educational materials to patients with dementia and their family caregivers.
• Document issues and care needs following the defined screening protocols, using standard tools.
• Provide proactive, timely communication to the clinical team regarding identified needs and issues.
• Identifies and screens community-based resources to address participant needs.
• Uses motivational interviewing strategies to help participants work toward their goals.
• Completes all assignments in Relias and signs all documents in PowerDMS on time.
• Willingly performs other duties as assigned.

 

Required Skills/Abilities:

• Excellent verbal and written communication and presentation skills.
• Strong organizational and interpersonal skills to work effectively in a diverse team.
• Proficiency with Microsoft Word, PowerPoint, and Windows.
• Excellent analytical and problem-solving skills.
• Ability to work effectively in a fast-paced, team-based environment; under supervision and direction, able to prioritize and complete tasks on time.
• Ability to establish cooperative working relationships with patients, co-workers, and health care/community service providers.

 

Education and Experience:

• High school diploma or equivalent required.  An associate’s degree or higher in social work, human services, aging services, or a related field is preferred
• Experience with clinical care, geriatrics, and/or patients with dementia is strongly preferred
• Certified Community Health Worker (CCHW) strongly preferred 
• Electronic medical records experience is strongly preferred
• Bilingual — verbal and written fluency in Spanish to serve a diverse population of patients and caregivers is strongly preferred

 

Hours

Monday – Friday; 8:30 AM – 5:00 PM

 

Location

Primary location will be Society Hill, SC. Will be required to travel throughout the Pee Dee region daily/weekly as needed.

 

CareSouth Carolina is committed to providing equal employment opportunities to all individuals. We welcome and encourage applications from all qualified individuals, without regard to race, color, age, sex, pregnancy, gender identity or expression, sexual orientation, religion, creed, national origin, ancestry, marital status, citizenship, genetic information, disability, military or veteran status, or any other characteristic protected by law.