Care Coach

Location: South Bend
FLSA Status: Non-Exempt
Job Type: Full Time


The Care Coach interacts directly with waiver participants with dementia and their caregivers and implements care protocols in collaboration with waiver care managers.


Customer Service: Delivers courteous, sincere, and sensitive customer service

  • Models Indiana’s Area Agencies on Aging Values and Mission
  • Timely in responding to participant/family/caregivers and other team member needs and requests
  • Explains actions reasonably and clearly to participants and caregivers
  • Displays positive beliefs and feelings regarding older adults
  • Displays level of comfort with older adults, caregivers and home visits


  • Independently manages data entry into the electronic record as well as documents appropriate information as required
  • Acquires and maintains competence in use of program hardware and software applications
  • Regularly utilizes technology as part of care delivery

Teamwork and Communication: Interacts regularly with all members of the care team to assure care coordination.

  • Communicates effectively with cognitively impaired participants
  • Remains composed and effective when faced with unexpected and uncomfortable situations
  • Participates in team care coordination/case conferences for assigned participants panel

 Care Delivery:

  • Conducts the participant/caregiver clinical and psychosocial needs assessments and follow-up visits in participants’ homes and by videoconferencing and telephone
  • Independently delivers care protocols in accordance with participant’s brain care plan and departmental standard operating procedures
  • Assists the care team in monitoring medication adherence
  • Completes accurate, timely, comprehensive documentation
  • Schedules participant and caregiver visits in accordance with participant’s brain care plan and departmental standard operating procedures
  • Provides community resource referrals, participant advocacy, support, outreach and follow-up
  • Provides education, training, and coaching to introduce or improve coping skills of participants and caregivers

Population Health Management

  • Participates in regular care coordination meetings/case conferences
  • Summarizes each participants’ clinical and psychosocial needs for team discussion
  • Demonstrates judgment and critical thinking skills in identifying participant’s needs and escalating to the care team as required by departmental protocols 


  • Serves as a participant advocate
  • Assists participants in connecting with healthcare and community resources
  • Answers phones/makes phone calls as needed/directed
  • Serves as a resource to staff on dementia care including support of caregivers
  • Completes assigned special projects


  • High School Diploma/GED required. Associate’s Degree, two years of related experience, and/or Community Health Worker Certification preferred.
  • Experience working with older adults preferred
  • Prior experience in a healthcare environment preferred


  • Maintains participant and family confidentiality
  • Maintains protected health information in accordance with HIPAA privacy guidelines and regulations
  • Able to work independently and prioritize tasks
  • Capable of handling multiple tasks concurrently
  • Demonstrates computer skills required including Microsoft word, excel, outlook and knowledge of electronic record systems
  • Exhibits professionalism in both written and verbal communication
  • High level of accuracy and attention to detail
  • Superior customer relations abilities
  • Works effectively with a wide variety of participants and participants families
  • Demonstrates positive beliefs and feelings regarding older adults


Employee may work independently under the general direction of their leader


  • Daily contact and interaction with participants, families, caregivers, care managers and other staff
  • Regular contact with community support organizations and program partners
  • Participation in initial dementia care training and periodic booster trainings  


  • Valid Driver’s License that meets the agency’s driving policy requirements


  • Will be required to travel to participants’ home
  • Will be required to attend meetings

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