Social Worker – Dementia Navigation Services (BSW)

Social Worker – Dementia Navigation Services (BSW)

In collaboration with the health care team, the social worker assists patients and families with personal and environmental difficulties with predisposed illness or interferes with obtaining maximum benefits from medical care. Services include providing patient and families with the psychosocial support needed to cope with disease and life limiting illness, advising family and caregivers, providing education and support, and making referrals for other services as needed or requested.

The Social Worker (BSW) provides care navigation, resource coordination, and supportive services to individuals living with dementia and their caregivers. This role focuses on guiding clients through healthcare, community resources, and long-term support systems while promoting quality of life, safety, and independence.

Key Responsibilities

• Conduct initial and ongoing assessments of individuals with dementia and their caregivers to identify needs, preferences, and barriers.
• Develop and implement individualized service plans in collaboration with clients, families, and interdisciplinary teams.
• Connect clients to appropriate medical, behavioral health, social, and community-based services (e.g., home health, adult day services, and respite care).
• Assist with transitions of care, including hospital discharge, long-term care placement, or in-home support expansion as needed.
• Provide education on dementia progression, caregiving strategies, and available resources.
• Offer emotional support and guidance to caregivers, addressing stress, burnout, and coping strategies.
• Advocate for client rights, dignity, and person-centered care approaches.
• Maintain knowledge of local, state, and federal programs (e.g., Medicaid waivers, aging services, transportation, housing supports).
• Assist clients with applications, referrals, and eligibility processes.
• Coordinate with community partners to ensure continuity of care.
• Monitor client progress and reassess needs monthly.
• Document all client interactions, care plans, and service outcomes in accordance with organizational and regulatory standards.
• Identify and address safety concerns, including risks related to wandering, medication, adherence, or neglect.
• Work closely with healthcare providers, case managers, and community organizations.
• Participate in interdisciplinary team meetings and case reviews.
• Support outreach efforts and community education related to dementia services.

What We Require:

Education: Bachelor's degree in social work required. Experience: Social work experience in health care setting preferred. Other: Critical thinking and creative problem-solving skills to move patients effectively and efficiently through the continuum of care. Ability and willingness to work as an integral member of a multi skilled team

Benefits, Pay and Well-being at Carilion Clinic

Carilion understands the importance of prioritizing your well-being to help you develop and thrive. That's why we offer a well-rounded benefits package, and many perks and well-being resources to help you live a happy, healthy life – at work and when you're away.

When you make your tomorrow with us, we'll enhance your potential to realize the best in yourself. Below are benefits available to you when you join Carilion:

• Comprehensive Medical, Dental, & Vision Benefits
• Employer Funded Pension Plan, vested after five years (Voluntary 403B)
• Paid Time Off (accrued from day one)
• Onsite fitness studios and discounts to our Carilion Wellness centers
• Access to our health and wellness app, Virgin Pulse
• Discounts on childcare
• Continued education and training