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% patient membership. You will serve as the primary contact for patients and focuses on care coordination, adherence coaching, healthcare navigation, transitions of care and reinforcing care plans.

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

Qualifications

• 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.
• Comfortable with regular home visits and community-based outreach.
• Demonstrated experience in patient education, care coordination, and social support of high-risk or geriatric populations.

Preferred Qualifications

• Active Unrestricted LPN/LVN license or MA Certification.
• Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license.
• Bilingual in English, Spanish and/or Creole with the ability to read/write/speak in both languages.
• Experience in care coordination, case management, population health and/or value-based care models.
• 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.

Benefits

• Health benefits effective day 1.
• Paid time off, holidays, volunteer time and jury duty pay.
• Recognition pay.
• 401(k) retirement savings plan with employer match.
• Tuition assistance.
• Scholarships for eligible dependents.
• Parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.
• Many other opportunities.