Dementia Care Manager-Guide Program

Community Name:

US OH RemoteThe Dementia Care Manager – GUIDE Program collaborates with designated UCH leaders for the
operational, quality, compliance, and service oversight of the organization's GUIDE program. The
position serves as a subject matter expert in dementia care and GUIDE program requirements and
exercises significant discretion and independent judgment in developing and implementing program
processes, evaluating service delivery, interpreting program requirements, resolving complex client
and caregiver needs, and recommending improvements to program operations.

The Manager provides leadership, direction, coaching, and oversight to GUIDE NaviGuides and is
responsible for establishing consistent standards for care coordination, documentation, client
engagement, caregiver support, and program compliance. The position monitors program
performance, evaluates operational needs, develops and implements processes, and collaborates with
internal and external partners to ensure the GUIDE program effectively meets organizational and

Medicare requirements.

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Program Administration & Operational Oversight

• Manage the day-to-day administrative and operational functions of the GUIDE program.

• Develop, implement, and evaluate program workflows, procedures, and service standards.

• Establish processes to support consistent and effective delivery of GUIDE services.

• Evaluate program capacity, staffing needs, caseload distribution, service delivery, and operational effectiveness.

• Identify operational challenges and independently develop recommendations and solutions.

• Make recommendations regarding program structure, staffing, resources, workflows, and service delivery.

• Monitor program growth, including expansion of the active GUIDE caseload from approximately 25 to 60–80 clients.

• Develop and implement processes to support program scalability while maintaining quality and compliance.

• Participate in short- and long-term planning for the GUIDE program.

GUIDE Compliance & Quality Management

• Maintain comprehensive knowledge of Medicare GUIDE requirements and translate regulatory and program requirements into operational practices.

• Develop and implement systems to monitor compliance with GUIDE requirements, organizational policies, privacy standards, documentation requirements, and quality expectations.

• Monitor the quality, accuracy, and timeliness of assessments, care plans, progress notes, referrals, and other required documentation.

• Review program data and documentation to identify trends, deficiencies, risks, and opportunities for improvement.

• Develop and implement corrective action plans when quality or compliance concerns are identified. · Monitor required GUIDE reporting and ensures program activities are completed within established timeframes.

• Evaluate the effectiveness of program processes and recommend modifications based on regulatory requirements, program data, client outcomes, and operational needs.

• Serve as a resource to leadership regarding GUIDE compliance, quality, and operational requirements.

Staff Oversight & Development

• Provide direct supervision, coaching, mentoring, and professional guidance to GUIDE NaviGuides.

• Establish performance expectations and monitor staff performance related to productivity, documentation, service quality, client engagement, and GUIDE compliance.

• Conduct regular supervisory meetings and performance evaluations. · Identify training and development needs and develop appropriate educational strategies.

• Develop and facilitate a dementia-specific training and staff development program for GUIDE NaviGuides.

• Provide consultation and guidance to NaviGuides regarding complex client, caregiver, care coordination, and service-related situations.

• Recommend changes to workflows, assignments, and service practices based on program needs and performance trends.

• Participate in interviewing and selection of GUIDE NaviGuides and provide input regarding hiring, performance, development, and other employment decisions, as appropriate

Caseload & Care Coordination

• Maintain an assigned GUIDE caseload and independently manage client and caregiver needs.

• Conduct initial in-home assessments and complete required GUIDE assessment tools, including FAST, ZBI-22, PROMIS-10, HRSN, and comprehensive assessments

. · Develop, implement, monitor, and update person-centered care plans.

• Complete required client and caregiver contacts and determine the appropriate frequency and method of follow-up based on individual needs.

• Exercise professional judgment in identifying changes in client or caregiver needs and determining appropriate interventions, referrals, and follow-up.

• Educate individuals and caregivers regarding dementia, available resources, supportive services, and strategies that promote independence, dignity, safety, connection, and quality of life.

• Serve as a liaison among clients, caregivers, primary care providers, GUIDE interdisciplinary team members, community agencies, and service providers

. Evaluate complex client and caregiver situations and determine appropriate resources, referrals, and interventions.

• Serve as an escalation resource for NaviGuides and assume responsibility for complex cases when additional expertise or intervention is needed.

• Maintain complete, accurate, and timely documentation in the electronic medical record

Program Training & Education

• Develop and maintain dementia-specific training for GUIDE NaviGuides.

• Assess staff training needs based on program changes, quality findings, regulatory requirements, and performance trends.

• Develop and facilitate educational programs for individuals, caregivers, employees, community partners, and GUIDE partner organizations.

• Serve as a subject matter expert regarding dementia care, caregiver support, community resources, and GUIDE services.

• Maintain current knowledge of dementia care practices, aging services, healthcare resources, benefits, and home- and community-based services.

Community & Healthcare Partnerships

• Develop and maintain relationships with hospitals, senior living communities, healthcare providers, community agencies, and GUIDE partner organizations.

• Represent the GUIDE program with external partners and community stakeholders.

• Identify opportunities to strengthen referral relationships and improve access to GUIDE services.

• Collaborate with the GUIDE Sales Manager regarding referrals, program capacity, geographic coverage, and client assignment.

• Evaluate available community resources and make recommendations regarding partnerships and resources that could enhance GUIDE services.

Systems, Data & Performance Management

• Oversee appropriate utilization of Welcome Home CRM and other systems used to manage GUIDE prospects, clients, referrals, caseloads, and program activity.

• Monitor data integrity and establish expectations for accurate and timely documentation. · Review program reports and data to evaluate productivity, caseload activity, service delivery, outcomes, and compliance.

• Analyze trends and use data to make recommendations regarding staffing, workflows, training, service delivery, and program improvements.

• Identify opportunities to improve efficiency, client outcomes, caregiver support, and overall program performance.

SKILLS & ABILITIES

Education:

Bachelor’s or Associate degree in Social Work, or Associate degree in Nursing is required; Bachelor’s degree or coursework in Gerontology preferred.

Experience: Two (2) or more years of experience providing social services or care coordination to older adults. Working knowledge of community resources and services within the geographic service area. Experience working with individuals living with Alzheimer’s disease or other forms of dementia, or experience in gerontology, is required.

Computer Skills: Must be able to operate a computer, the Internet, Microsoft Office, other relevant software, and basic office equipment.

Certifications & Licenses: Membership in and familiarity with the American Association of Service Coordinators is helpful. A valid driver’s license is required, and the individual must meet company vehicle insurance and driving record standards. Certified Dementia Practitioner (CDP) certification or an equivalent dementia-related certification is preferred.

Other Requirements: Proven experience in service management or facilitation, including organizing, problem-solving, and advocating; Must be able to read, write, understand and speak the English language; Must have strong interpersonal and communication skills; Must be able to work closely with residents, family members, legal representatives, and housing community staff; Must function independently, have a high level of flexibility and personal integrity; Must be able to adhere to all terms and conditions set forth in the United Church Homes Employee Handbook.

We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Originally posted on Himalayas