MSW-Home Health

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Job Title

Care Navigator (Family Caregiver Support) – Home-Based Care Pilot

Job Summary

JAA is launching an innovative pilot program designed to help older adults with complex health needs remain safely at home by better supporting and engaging family caregivers.

Family and community caregivers are often the first to notice subtle changes—yet they’re frequently under-supported, under-trained, and unsure how to escalate concerns. This pilot tests whether a supported and trained caregiver, paired with clear workflows and a Care Navigator, can help identify issues earlier and reduce avoidable ER visits and hospitalizations.

The Care Navigator will be the day-to-day hub for participating caregivers—building trust, facilitating caregiver “huddles”, monitoring caregiver check-ins, coordinating follow-up, and partnering closely with JAA’s clinical team and pilot partners.

Who thrives here: someone who’s energized by helping families in real life (not on paper), comfortable making judgment calls, and excited to learn and improve a new model as we go.

Role Type / Compensation

● Salaried position, for a 12 month period (May 1 - May 1), with the potential to extend beyond this period.

● After-hours on call will be required to support a small (50 patients max) population for critical escalations

Key ResponsibilitiesMonitor check-ins and coordinate follow-up

● Monitors the pilot cohort (~50 families) for changes in patient status and caregiver-reported concerns, coordinating early intervention and care transitions to help prevent avoidable hospitalizations.

● Coordinates post-hospitalization follow-up to support a smooth and safe transition back homeț

● Review caregiver check-ins (including daily surveys) and flag concerns

● Create and track follow-up items from caregiver huddles and surveys

● Support caregivers with problem-solving and navigation (resources, next steps, practical barriers)

● Work closely with Integra Strategies to learn best practices related to caregiver check-ins and follow up.

Support & guide family caregivers

● Build trusting relationships with caregivers and help create a sense of community and psychological safety

● Assists patients and family members by providing education and support.

● Facilitate daily small-group virtual caregiver huddles to support, concerns, celebrations, escalation prompts, (describe green/yellow/red system)

● Help caregivers understand what to watch for (per HHA clinically supported care plan), how to communicate concerns, and how to follow the program flow

Triage and escalation

● Use JAA defined protocols and good judgment to determine when to:

○ route to JAA clinical staff (in-episode / clinical concerns)

○ guide caregivers toward appropriate non-clinical resources

○ recommend next steps (e.g., contact PCP, schedule visit, obtain supplies)

● Coordinate closely with JAA nursing / clinical team to ensure concerns are addressed and closed-looped

Occasional home visits

● Conduct home visits for onboarding support, build relationships, observation, and/or to help caregivers navigate care pathways and resources (not hands-on clinical care)

Pilot implementation & improvement

● Partner with the JAA team and pilot partner (Rubywell, Integra Strategies) to improve workflows over time:

○ what caregivers can realistically do

○ what’s confusing vs. effective

○ what to change in huddles/surveys/resources to improve engagement and outcomes

● Provide clear, candid feedback based on caregiver experience and operational reality, and participate in regularly program and product review sessions with RubyWell.

QualificationsRequired

● MSW

● At least 2 years in a people-facing role in home health, care coordination, social services, community health, aging services, or a related setting. Must have been focused on aging population.

● Comfort entering a wide range of home environments and working with families under stress

● Strong facilitation presence: you can guide a group conversation with warmth and confidence

● Excellent follow-through: you can juggle many threads, track action items, and close loops

● Sound judgment and good boundaries: you know what’s under your umbrella and when to escalate

Preferred (not required)

● Experience with caregiver support groups, dementia/complex chronic care, or home-based care programs

● Familiarity with local/community resources (aging, benefits, caregiver supports)

Skills & Disposition We Value

● Relationship Builder: this role is primarily about creating a trusted, supported connection with families

● Confident humility: you can say “I don’t know, but I’ll find out,” and people trust you

● Resourceful and practical: you find a path through barriers without needing perfect conditions

● Calm under pressure: families may be overwhelmed; you can be steady and grounded

● Adaptable: you’re comfortable building and refining a new program while operating it, adjusting to frequent change

● Tech-comfortable enough: can support caregivers with simple digital workflows (text-based surveys, virtual huddles, basic tools)

Physical Requirements

• Lifting: Regularly lifts and moves patients, equipment, patient supplies. Frequently lifts up to 40 pounds. Occasionally lifts and moves patients unassisted up to 50 pounds.
• Carrying: Carries medical supplies, and other items, weighing up to 30 pounds.
• Climbing: Ability to use stairs, curbs, and walkways in order to access patient’s functional abilities.
• Bending: Required when administering patient care.
• Reaching/Turning/Twisting: May be required when administering care.
• Repetitive Motions:
• Hands: required for certain aspects of patient care such as simple grasping, fine manipulation.
• Feet: Ability to walk and stand for various duties.

EOE

Pay: $60.00 per year

Benefits:

• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Pet insurance
• Retirement plan
• Vision insurance

Work Location: In person