General Summary of Position
The GUIDE Care Manager is responsible for the delivery, multidisciplinary coordination and oversight of care management services for patients living with dementia and their caregivers/family. The primary focus of the GUIDE model and this role is to ensure high-quality care delivery and caregiver support to keep patients living with dementia in the home setting for as long as possible.

Primary Duties and Responsibilities

Patient Advocacy: Acts as a liaison between patients, caregivers, healthcare providers and other support services to ensure patient and caregiver needs are met in a timely and effective manner

Assessments: Conducts an initial assessment of the patient's physical, social, emotional, and educational needs and based on this assessment, implements and manages an individualized plan of care for the patient that is inclusive of care giver needs. Manages and monitors effectiveness of plan of care and adjusts accordingly based on changes in health status or needs.

Triage and Crisis Management: Responds to on-demand patient/caregiver requests, escalating to providers and or services as appropriate to support clinical, social and or behavioral/emotional needs.

Care Management: Provides emotional and psychosocial support to the patient and their caregiver. Contacts each patient/caregiver according to a schedule based on identified and anticipated needs, dementia diagnosis severity and rising risk. This may include in-home visits. Conducts post utilization outreach to ensure smooth transitions of care. In collaboration with the care team, provides initial and ongoing education to patient, family/caregiver. The education can include information concerning their diagnosis, medication management, plan of care and effective care strategies and techniques to promote self-management and desired patient outcomes.

Leadership: Provides oversight, development and performance management of Care Navigators.

Interdisciplinary Collaboration: Establishes and maintains an effective communication system with physicians and other members of the multidisciplinary team caring for the patients/caregiver. Collaborates with all disciplines (primary care and specialists) to ensure a collaborative patient-centered approach to care and implementation of the therapy regime.

Regulatory Compliance: Adheres to all CMS GUIDE requirements and reporting, ensuring compliant documentation of the provision of comprehensive care management services.

Continuous Improvement: Coordinates and conducts quality improvement activities including surveys from patients and caregivers, referring physicians, staff, and the effectiveness of the plan of care on patient outcomes. Maintains a mindset of continuous improvement, identifying short- and long-term opportunities to enhance program effectiveness.

Education: Develops an inventory of educational resources for acute-care, ambulatory providers, practice sites and the general public. Develops patients/families/caregivers educational standards based on identified need and dementia diagnosis severity.

GUIDE Liaison: Serves as a clinical resource expert for marketing, physician, and community outreach. Develops and maintains partnerships with clinicians to promote utilization of MedStar Health GUIDE Model.

Collaboration: Establishes community and enterprise relationships and works effectively within and between departments, community-based organizations and with key stakeholders. Maintains knowledge of community-based services and support for effective referral management. Participates on inter-departmental teams, committees and other external organizations as directed. Demonstrates a constructive approach during all interactions with staff and GUIDE collaborators.

Professional Development: Completes all required GUIDE training and departmental/organizational mandatory requirements including those to maintain licensure. Maintains knowledge of evidence- based practices in dementia care, care management and caregiver support. Practices within legal boundaries of nurse practice act and according to MedStar Health policy and procedures. Identifies self-learning needs and initiates actions to address these education needs.

May participate in on call support outside of regular hours on an as needed basis

Minimum Qualifications
Education

Bachelor's degree Nursing required

Experience

3-4 years Nursing care delivery, 5+ years preferred required and
1-2 years Supervisor or Manager experience preferred

Licenses and Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure Maryland Nursing License/Virginia Nursing License (Compact) DC Nursing License Upon Hire required

Knowledge, Skills, and Abilities

Ability to communicate effectively with all internal and external customers
Ability to work independently and as part of an interdisciplinary team
Strong organizational and time-management skills
Experience with complex chronic disease populations including geriatrics and dementia, case/care management services
Proficient in electronic health record (EHR) systems and documentation
Proficient in Microsoft Office Suite

This position has a hiring range of $87,318 - $157,289

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Primary Duties and Responsibilities

Patient Advocacy: Acts as a liaison between patients, caregivers, healthcare providers and other support services to ensure patient and caregiver needs are met in a timely and effective manner

Triage and Crisis Management: Responds to on-demand patient/caregiver requests, escalating to providers and or services as appropriate to support clinical, social and or behavioral/emotional needs.

Leadership: Provides oversight, development and performance management of Care Navigators.

Regulatory Compliance: Adheres to all CMS GUIDE requirements and reporting, ensuring compliant documentation of the provision of comprehensive care management services.

May participate in on call support outside of regular hours on an as needed basis

Minimum Qualifications
Education

Bachelor's degree Nursing required

Experience

3-4 years Nursing care delivery, 5+ years preferred required and
1-2 years Supervisor or Manager experience preferred

Licenses and Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure Maryland Nursing License/Virginia Nursing License (Compact) DC Nursing License Upon Hire required

Knowledge, Skills, and Abilities

Ability to communicate effectively with all internal and external customers
Ability to work independently and as part of an interdisciplinary team
Strong organizational and time-management skills
Experience with complex chronic disease populations including geriatrics and dementia, case/care management services
Proficient in electronic health record (EHR) systems and documentation
Proficient in Microsoft Office Suite

This position has a hiring range of $87,318 - $157,289

Job ID: 482365815

Originally Posted on: 6/23/2025