Integrated Care Coach

About the role

The Care Coach provides proactive, patient-centered care coordination and social needs support for the highest-risk top 5% of patient membership. You will serve as the primary contact for patients, focusing on care coordination, adherence coaching, healthcare navigation, transitions of care, and reinforcing care plans. This role reports to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization.

Responsibilities

• Clinical Screening & Escalation: Conduct structured patient interviews and collect health-related information (e.g., medication regimen and barriers to adherence, social barriers, functional status). Document and share findings with providers.
• Outreach and Home Visits: Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement.
• Social Needs Support: Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources.
• Chronic Disease Education: Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management.
• Care Coordination: Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers. Support care transitions, coordinate follow-up, and facilitate communication across care settings to close care gaps. Partner closely with the primary care provider to create care plans and priority action items.
• Post-Hospital and Emergency Department Follow-Up: Conduct timely follow-up after hospitalizations and emergency department visits to support safe transitions. Review discharge instructions, schedule/confirm follow-up appointments, verify patient-reported medications, and escalate discrepancies to providers.
• Community Engagement: Encourage and support patient connection to community-based programs that reinforce health goals, including initial engagement when appropriate.
• Cultural Competence: Deliver patient-centered, culturally sensitive care that respects patients' beliefs, preferences, and social context.
• Develop a holistic understanding of patient needs via a 5Ms framework (What Matters Most, Mind (Mentation), Mobility, Medications, Multi-complexity) and identify barriers impacting health outcomes.
• Prepare, participate, and discuss patients during High-Risk Rounds.

Requirements

• Healthcare professional with 3+ years of ambulatory, primary care, or senior-care experience with direct patient care.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfortability to regularly conduct home visits and community-based outreach.
• Demonstrated experience in patient education, care coordination, and social support of high-risk or geriatric populations.

Qualifications

Preferred Qualifications:

• Active unrestricted LPN/LVN license or MA Certification.
• Licensed or unlicensed medical professional with equivalent foreign Registered Nurse (RN) or Physician license.
• Experience in care coordination, case management, population health, and/or value-based care models.
• Experience conducting post-hospital/ED follow-up with appropriate escalation.
• Familiarity with Medicaid, Long-term Care, and HCBS programs.
• Experience working with seniors and medically complex populations.
• Prior home visit experience and knowledge of field safety practices.
• Bilingual in English and Spanish with the ability to read/write/speak in both languages.

Workstyle & Location

This role has a mobile presence, involving travel to patients' homes, healthcare facilities, community-based settings, and assigned clinics. Workstyle is a combination of clinic-based and field work. Must reside in the designated market area.

Schedule

Monday–Friday, 8:00 AM–5:00 PM; overtime may be required.

Scheduled weekly hours: 40.

Pay

The pay range reflects a good faith estimate of starting base pay for full-time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location, and individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, and certifications.

$53,700 - $72,600 per year.

This job is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

Humana offers competitive benefits that support whole-person well-being, including:

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment, and more. Our unique care model focuses on personalized experiences, taking time to listen, learn, and address the factors that impact patient well-being. Our integrated care teams spend up to 50% more time with patients, providing compassionate, personalized care that leads to better health outcomes. We address not only physical health but also other factors that impact well-being.

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put patients at the center of everything we do. As the largest provider of senior-focused primary care, a leading provider of home healthcare, and a leading integrated home delivery, specialty, hospice, and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional, and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM).