Position Summary:

The Community Health Worker (CHW) plays a critical role in supporting practice's implementation and ongoing operations of the CMS GUIDE (Guiding an Improved Dementia Experience) Model. The CHW will serve as a primary point of contact for patients living with dementia and their caregivers, focusing on outreach, education, care navigation, coordination with partner organizations, and administrative tasks required for program participation and compliance. This position will begin with a pre-implementation focus on aligning eligible patients for GUIDE visits and transition into ongoing responsibilities that include monthly outreach, documentation, claims support, and caregiver engagement.

Key Responsibilities:

Conduct outreach to approximately 250 eligible patients and caregivers to introduce the GUIDE Model and schedule alignment visits with providers.
Document outreach efforts and maintain accurate tracking of scheduled, pending, and completed alignment visits.
Coordinate between practice providers and partner organizations such as the Alzheimer’s Association, respite programs, and community services to prepare for GUIDE enrollment.
Participate in care navigator and GUIDE-specific training sessions.
Support administrative setup tasks, including forms preparation, caregiver communication templates, and visit tracking systems.
Perform monthly follow-up calls to enrolled patients and caregivers to assess needs, reinforce education, and offer connection to resources.
Track and document all interactions, caregiver needs, referrals, and service updates in accordance with CMS GUIDE Model requirements.
Assist with administrative tasks, including confirming GUIDE visit completion, ensuring documentation compliance, and preparing visit records for coding and billing review.
Collaborate with practice's billing and coding team to help ensure GUIDE-related encounters are correctly submitted to CMS, including gathering supporting documentation.
Coordinate annual assessments, caregiver service delivery, and respite referrals as required by the model.
Prepare and support GUIDE-related reporting and quality improvement initiatives, including data entry and summary reports.
Serve as a liaison between patients, caregivers, providers, and community-based organizations to promote continuity and reduce fragmentation of care.
Attend regular GUIDE program meetings and contribute to continuous improvement efforts across workflows and patient experience.

Experience in healthcare, social work, public health, or community outreach strongly preferred.
Familiarity with dementia care, caregiver needs, and health system navigation is an asset.
Strong communication, organization, and documentation skills.
Comfort using EHRs, tracking tools, and CMS-aligned documentation systems.
Ability to work independently while collaborating with interdisciplinary team members.
Compassionate, patient-centered mindset with a commitment to improving care for aging populations.

AMG Senior Medical Group

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