Care Navigator - GUIDE Program at Five Star Home Health Care – Chantilly, Virginia

Care Navigator for GUIDE Program

Location: 100% office-based in Chantilly, VA

Salary Range: $68,000-$88,000 (based on experience)

Reports To: Administrator

Employment Type: Full Time, Salaried with Benefits

Position Summary:

The Care Navigator supports individuals living with dementia and their caregivers by providing comprehensive, person‑centered care navigation in alignment with CMS’s GUIDE (Guiding an Improved Dementia Experience) Model. This role focuses on care coordination, resource linkage, caregiver education and ongoing support across the dementia care journey. A Medical Social Worker (MSW) is strongly preferred.

Key Responsibilities:

• Serve as the primary point of contact for individuals with dementia and their family caregivers
• Along with our Provider, develop and monitor individualized care plans in collaboration with care team
• Coordinate medical, behavioral health and community-based services
• Provide caregiver education, coaching and emotional support
• Support care transitions, including hospital discharges and changes in level of care
• Facilitate referrals to community resources (e.g., respite care, benefits, transportation, nutrition, housing)
• Document care navigation activities and outcomes in compliance with CMS GUIDE requirements
• Participate in team meetings, case reviews and quality improvement activities

Qualifications:

• Medical Social Worker strongly preferred
• Extensive training and experience with all forms of dementia
• Experience working with older adults, dementia, chronic illness, or caregiver support programs
• Knowledge of Medicare, Medicaid, and community-based services